Delta Variant: Expanding the Indication for Eluxadoline to Bile Acid Diarrhea

Excerpt

Diarrhea-predominant irritable bowel syndrome (IBS-D) is a heterogeneous condition that is broadly defined by the presence of chronic abdominal pain and loose stools [1]. As carefully delineated in a recent narrative review by Camilleri et al., bile acid diarrhea (BAD) is a disease characterized by enteric malabsorption of bile acids that are important to enterohepatic communication and gut microbiota signaling [2]. Indeed, the primary symptoms of BAD include urgency to defecate, abdominal pain, and occasional accidental bowel leakage/fecal incontinence. The management paradigm for BAD has focused sensibly on identifying bile acid malabsorption and to broadly provide bile acid sequestrants or to promote a low-fat diet as the field has emerged over the past decades. More recently, ongoing clinical trials have demonstrated that investigational nuclear farnesoid X receptor (FXR) agonists are capable of improving key symptoms of BAD in a manner that more specifically targets the underlying pathophysiologic mechanism by decreasing the synthesis of hepatic bile acids through feedback inhibition [3]. Given that symptoms of IBS-D and BAD significantly overlap, it is possible that patients with BAD may be empirically treated with non-targeted IBS-D treatments and that patients with BAD might experience some level of general clinical improvement with this purely symptom-based approach to care [4]. To truly achieve the promise of personalized medicine, there remains a clear opportunity for diagnostic paradigms to more accurately target therapy tied to underlying disease mechanisms such as BAD. …