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Effect of fibre, antispasmodics, and peppermint

oil in the treatment of irritable bowel syndrome:
systematic review and meta-analysis.
Ford AC, Talley NJ, Speigel BMR, et al. BMJ
2008;337:a2313

APPRAISAL OF A SYSTEMATIC REVIEW

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Clearly-focused question
The right type of study included
Identifying all relevant studies
Assessment of quality of studies
Reasonable to combine studies
What were the results
Preciseness of results
Application of results to local population
Consideration of all outcomes
Policy or practice change as a result of evidence
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CASP

1. CLEARLY-FOCUSED

QUESTION

Is the question clearly focused?

the effect of fibre, antispasmodics, and
peppermint oil in the treatment of irritable
bowel syndrome.

CLEARLY-FOCUSED QUESTION
The

population
adults (>16 years) with a diagnosis of irritable
bowel syndrome
The intervention
fibre, antispasmodics, and peppermint oil
Comparator
placebo or no treatment.
Outcome
global assessment of cure or improvement of
symptoms, or cure or improvement of abdominal
pain, after treatment. This was preferably as
reported by the patient, but could be documented
by a doctor. I

2. THE RIGHT TYPE OF STUDY INCLUDED

Studies

included:
Randomised controlled trials

IDENTIFYING ALL RELEVANT STUDIES

Bibliographic databases used
Medline (1950 to April 2008), Embase (1980 to April 2008),
and the Cochrane controlled trials register (2007)

Search strategy:
Multiple combinations

Language:
No restrictions

Other sources:
We hand searched abstract books of conference proceedings
between 2001 and 2007 to identify potentially eligible studies.
The reference lists of all identified relevant studies were used
to carry out a recursive search of the literature.

3. IDENTIFYING ALL RELEVANT STUDIES

Search:
3 Databases, comprehensive search term, no
language restrictions, gray literature, reference list

Inclusion evaluation:

Two reviewers independently assessed articles

using predesigned eligibility forms, according to
eligibility criteria defined prospectively. Any
disagreement between investigators was resolved
by consensus.

4. ASSESSMENT OF QUALITY OF STUDIES

Study quality
Two reviewers independently assessed study
quality according to the Jadad scale. This records
whether a study is described as randomised and
double blind, the methods for generation of the
allocation schedule and double blinding, and
whether there is a description of dropouts during
the trial.

Look at tables 1,2,3

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4. QUALITY: WHAT TO CONSIDER

Few studies are done in primary health care. Are

these patients different?
Many trials are short term (few weeks), small
sample. How this limits the data?

5. REASONABLE TO COMBINE STUDIES

Data combination
combines the RCTs looking at bran and antispasmodics
as a group and peppermint oil as an individual agent
(with sensitivity for bran/antispasmodics types)

Synthesis
Look at Data synthesis and statistical analysis

pooled data using a random effects model to give a

more conservative estimate of the effect of individual
treatments, allowing for any heterogeneity between
studies
Publication bias and heterogeneity were evaluated

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6. WHAT WERE THE RESULTS

The study reports absolute numbers, NNT, RR,

provides plots

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7. PRECISENESS OF RESULTS

Forest plot
shows how the
results vary by
individual agent
and RCT
Study presents
p, CI, impact of
heterogeneity/
quality
LOOK
FIGURES

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APPLICATION OF RESULTS TO LOCAL

POPULATION

Countries of origin are listed for RCT

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CONSIDERATION OF ALL OUTCOMES

Outcomes are trial-dependent

Check Table 3

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10. POLICY OR PRACTICE CHANGE AS A

RESULT OF EVIDENCE

Recommendations:

WHAT THIS STUDY ADDS

Fibre, antispasmodics (particularly hyoscine and
otilonium), and peppermint oil were all more
effective than placebo for treating irritable bowel
syndrome The numbers needed to treat with these
therapies were 11, 5, and 2.5, respectively. Doctors
should consider ispaghula, antispasmodics
(preferably hyoscine as first line treatment), and
peppermint oil to treat irritable bowel syndrome

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