Zsa Zsa Weerts

Efficacy and safety of peppermint oil in IBS 159 7 taken together, do not support the use or further development of this formulation for treatment in patients with IBS. The reason for increased reporting of abdominal cramps upon administration of ileocolonic release peppermint oil is unclear and unexpected given the smooth muscle relaxatory effects of the agent. As far as the effects of peppermint oil are concerned and on the basis of these findings, however, we speculate that the small intestine could be of superior importance compared to the colon with regards to pain symptom generation and relief in IBS. In addition, considering the late onset of beneficial effects, we further postulate the involvement of TRP channels on intestinal sensory afferents rather than a primarily antispasmodic effect that is assumed to occur more rapidly. Currently, treatment of IBS is often tailored towards improvement of patient’s most predominant symptom. If initial treatment fails to achieve satisfactory results, linaclotide and eluxadoline are examples of recent pharmacological advancements that have led to novel drug development and can be used to treat constipation- and diarrheal-type IBS, respectively. Despite high quality evidence, their somewhat less favorable adverse event profile should be considered and may limit applicability. 38,40 Of the therapeutic entities available for IBS, none has been able to cure or alter the disorder on the long-term. This reflects our incomplete pathophysiological understanding of IBS, which leads to the inability to target specific disease mechanisms. In this perspective and in view of our findings, peppermint oil appears to be a favorable initial treatment entity in IBS owing to the following reasons: 1) peppermint oil is readily available as a low-cost OTC drug; 2) adverse events are at most mild and transient of nature; 3) using a pharmacological agent of herbal origin without the risk of serious adverse events could be attractive for patients. In fact, in the Netherlands, peppermint oil was the most preferred treatment option when given the choice of ten treatment options (education on IBS, other antispasmodics, antidepressants, and elimination/FODMAP diet included). 44 It is worth noting that because improvements in exploratory secondary outcomes were observed rather towards the end of the treatment period, and belching arises at the beginning of treatment, but normalizes soon after, patients should be encouraged to continue treatment. Finally, to avoid disappointment, providers could communicate that there is little evidence for long-term beneficial effects after discontinuing with peppermint oil treatment. Future research should investigate the safety and effect of longer treatment periods. This study has several limitations. First, the population was relatively young, female, and predominantly of Caucasian origin; therefore, data may not necessarily be generalizable to more diverse IBS populations. We speculate that the use of social media as a