Protocol development in integrative medicine is not typically a simple process. Individuals require individualized care, and what works for one patient may not work for another.

To establish these protocols, we first developed a Rating Scale that could be used to discern the rigor of evidence supporting a specific nutrient’s therapeutic effect.

The following protocols were developed using only -quality evidence.

Class
Qualifying studies
Minimum requirements

Dysfunctional gastrointestinal processes vary widely. Chronic abdominal pain with persistent or recurrent tendencies may be associated with abnormalities in bowel function and structure. The prevalence of gastrointestinal problems presenting in this way ranges anywhere from 5 to 20% of people being affected. (7)

Depending on the symptoms presented, there are a variety of ways to help ameliorate symptoms. For example, antispasmodics such as peppermint oil can help with pain associated with digestive dysfunction. (11) Both probiotics and fiber contribute to improving stool consistency through the mechanism of creating a healthy microbiota, (9)(19) which can lend to easier passing as well as serving as an indicator for digestive health. Having integral intestinal permeability helps the body absorb nutrients and dispose of waste properly; the amino acid glutamine helps to improve this function and may contribute to better digestion. (17)(20)

Based on current research findings, the ingredients in the protocol below have demonstrated efficacy in improving a variety of factors associated with gastrointestinal upset or digestive dysfunction.

Support your treatment plan with this low-FODMAP handout for patients.

Peppermint oil

180 mg, three times per day, minimum four weeks (3) 

  • 42.4% of patients with IBS were pain-free after 8 weeks of supplementation with delayed-release peppermint oil, compared to 22.2% in placebo. The proportion of patients reporting persistent pain decreased from 42% to 15% in the peppermint oil group, whereas it increased from 33% to 52% in the placebo group (11)
  • Peppermint oil supplementation ameliorated symptoms of IBS at 24 hours shown by a decrease in Total IBS Symptom Score (TISS) of 19.6%, compared to 10.3% in the placebo group; after 4 weeks, the decrease in TISS scores were 40% in the treatment group, compared to 24.3% in the placebo group (3)
  • 75% of patients treated with enteric-coated peppermint oil capsules for four weeks experienced at least a 50% reduction in TISS scores compared to 38% in the placebo group (2)
Peppermint oil in the Fullscript catalog

Soluble dietary fiber

Ranges widely, from 4.1-40.0 g per day for 3-16 weeks (12) 

  • A systematic review of 22 studies with dose ranging 4.1-40.0 g/day for 3-16 weeks determined that soluble (but not insoluble) fiber supplementation resulted in a significant improvement in global assessment of symptoms (RR 1.49) as well as abdominal pain scores (12)
  • In patients with tendency toward diarrhea (IBS-D), 5 g/day of soluble fiber of partially hydrolyzed guar gum improved and normalized bristol stool scale ratings after 3 months compared to placebo (19)
  • After 10 g/day for 12 weeks, symptom severity improved by 90 points in psyllium group (RR 1.60), compared to 29 points in placebo and 58 points in bran groups, in patients with IBS aged 18 to 65; it is notable that the group receiving bran had a high dropout rate due to symptoms of IBS worsening (1)
  • A systematic review of 14 studies involving 906 patients found that soluble fiber (but not insoluble fiber) significantly improved IBS symptoms (RR 0.86) (6)
Fiber in the Fullscript catalog

Probiotics

50 billion CFU, twice per day, minimum 12 weeks (15)  or 25-50 billion CFU, one to three times per day (5)  

Note: Dosages vary widely across studies and product formulations; depending on the patient’s individual needs, we recommended referring to our Probiotics Guide Part 1, which provides a detailed look at the various strains that benefit gastrointestinal conditions.

  • A systematic review of 15 studies with 1793 patients found that probiotics reduced pain and symptom severity scores in patients with IBS; relative risk (RR) of general symptom improvement for 7 of the key trials was 2.14, in favor of probiotics over placebo (5)
  • Another systematic review of 43 RCTs found that probiotics reduced the risk of persistent symptoms compared to placebo (RR 0.79); benefits were seen among global IBS, abdominal pain, bloating, and flatulence scores (6)
  • A recent systematic review showed that 7/11 of the included studies reported improved IBS symptoms from probiotic supplementation compared to placebo; multi-strain probiotics with an intervention of 8 weeks or more were more likely to have a benefit (4)
  • Female patients with IBS-D (diarrhea predominant IBS) and IBS-C (constipation predominant IBS) improved quality of life, stool frequency, and consistency when supplemented with 2 capsules per day of probiotics containing 50×10^9 CFU of live organisms of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, and Lactobacillus rhamnosus CLR2 for 12 weeks (15)
Probiotics in the Fullscript catalog

Ginger

1200 mg, 1 hour before eating, as needed (8)(18)

  • Patients with mild to moderate ulcerative colitis experienced a decreased severity of disease activity as well as in improvement in quality of life scores after 12 weeks of supplementation at 2000 mg/day, compared to placebo; malondialdehyde levels (but not total antioxidant capacity) also decreased at both 6 and 12 weeks (13)
  • Digestion improved in two RCTs as shown by a faster gastric half-emptying time and increased antral contractions in treatment group (1200 mg/day ginger capsule) compared to placebo (8)(18)
  • Patients with a history of motion sickness experienced a delayed onset of nausea after vection cessation as well as a decrease in tachygastria activity and vasopressin release (10)
Ginger in the Fullscript catalog

Glutamine

5 g, two to three times daily, for eight weeks (20)

  • Intestinal hyperpermeability improved in burn victims given 0.5 g/kg/day for 14 days, compared to placebo (14)
  • Acute glutamine administration at 0.25-0.9 g/kg fat-free mass 2 hours prior to running in a heat chamber has been shown to reduce GI permeability in a dose-dependent manner (16)
  • Adults with IBS-D symptoms following a GI infection were given 5 g/t.i.d. Glutamine or placebo for 8 weeks; 79.6% of patients in the glutamine group experienced at least a 50 point reduction in IBSS scores, compared to 5.8% in the placebo group (20)
Glutamine in the Fullscript catalog

Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

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References
  1. Bijkerk, C. J., de Wit, N. J., Muris, J. W. M., Whorwell, P. J., Knottnerus, J. A., & Hoes, A. W. (2009). Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ , 339, b3154. https://pubmed.ncbi.nlm.nih.gov/19713235/ (B)
  2. Cappello, G., Spezzaferro, M., Grossi, L., Manzoli, L., & Marzio, L. (2007). Peppermint oil (Mintoil) in the treatment of irritable bowel syndrome: a prospective double blind placebo-controlled randomized trial. Digestive and Liver Disease: Official Journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver, 39 (6), 530–536. https://pubmed.ncbi.nlm.nih.gov/17420159/ (B)
  3. Cash, B. D., Epstein, M. S., & Shah, S. M. (2016). A Novel Delivery System of Peppermint Oil Is an Effective Therapy for Irritable Bowel Syndrome Symptoms. Digestive Diseases and Sciences, 61 (2), 560–571. https://pubmed.ncbi.nlm.nih.gov/26319955/ (B)
  4. Dale, H. F., Rasmussen, S. H., Asiller, Ö. Ö., & Lied, G. A. (2019). Probiotics in Irritable Bowel Syndrome: An Up-to-Date Systematic Review. Nutrients, 11 (9). https://pubmed.ncbi.nlm.nih.gov/31480656/ (A)
  5. Didari, T., Mozaffari, S., Nikfar, S., & Abdollahi, M. (2015). Effectiveness of probiotics in irritable bowel syndrome: Updated systematic review with meta-analysis. World Journal of Gastroenterology: WJG, 21 (10), 3072–3084. (A)
  6. Ford, A. C., Quigley, E. M. M., Lacy, B. E., Lembo, A. J., Saito, Y. A., Schiller, L. R., Soffer, E. E., Spiegel, B. M. R., & Moayyedi, P. (2014). Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis. The American Journal of Gastroenterology, 109 (10), 1547–1561; quiz 1546, 1562. https://pubmed.ncbi.nlm.nih.gov/25070054/ (A)
  7. Ford, A. C., & Vandvik, P. O. (2012). Irritable bowel syndrome. BMJ Clinical Evidence, 2012. https://pubmed.ncbi.nlm.nih.gov/22296841/ (A)
  8. Hu, M.-L., Rayner, C. K., Wu, K.-L., Chuah, S.-K., Tai, W.-C., Chou, Y.-P., Chiu, Y.-C., Chiu, K.-W., & Hu, T.-H. (2011). Effect of ginger on gastric motility and symptoms of functional dyspepsia. World Journal of Gastroenterology: WJG, 17 (1), 105–110. https://pubmed.ncbi.nlm.nih.gov/21218090/ (C)
  9. Liang, D., Longgui, N., & Guoqiang, X. (2019). Efficacy of different probiotic protocols in irritable bowel syndrome: A network meta-analysis. Medicine, 98 (27), e16068. https://pubmed.ncbi.nlm.nih.gov/31277101/ (A) 
  10. Lien, H.-C., Sun, W. M., Chen, Y.-H., Kim, H., Hasler, W., & Owyang, C. (2003). Effects of ginger on motion sickness and gastric slow-wave dysrhythmias induced by circular vection. American Journal of Physiology. Gastrointestinal and Liver Physiology, 284 (3), G481–G489. https://pubmed.ncbi.nlm.nih.gov/12576305/ (C)
  11. Merat, S., Khalili, S., Mostajabi, P., Ghorbani, A., Ansari, R., & Malekzadeh, R. (2010). The effect of enteric-coated, delayed-release peppermint oil on irritable bowel syndrome. Digestive Diseases and Sciences, 55 (5), 1385–1390. https://pubmed.ncbi.nlm.nih.gov/19507027/ (B)
  12. Nagarajan, N., Morden, A., Bischof, D., King, E. A., Kosztowski, M., Wick, E. C., & Stein, E. M. (2015). The role of fiber supplementation in the treatment of irritable bowel syndrome: a systematic review and meta-analysis. European Journal of Gastroenterology & Hepatology, 27 (9), 1002–1010. https://pubmed.ncbi.nlm.nih.gov/26148247/ (A)
  13. Nikkhah-Bodaghi, M., Maleki, I., Agah, S., & Hekmatdoost, A. (2019). Zingiber officinale and oxidative stress in patients with ulcerative colitis: A randomized, placebo-controlled, clinical trial. Complementary Therapies in Medicine, 43, 1–6. https://pubmed.ncbi.nlm.nih.gov/30935515/ (C)
  14. Peng, X., Yan, H., You, Z., Wang, P., & Wang, S. (2004). Effects of enteral supplementation with glutamine granules on intestinal mucosal barrier function in severe burned patients. Burns: Journal of the International Society for Burn Injuries, 30 (2), 135–139. https://pubmed.ncbi.nlm.nih.gov/15019120/ (C)
  15. Preston, K., Krumian, R., Hattner, J., de Montigny, D., Stewart, M., & Gaddam, S. (2018). Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 improve quality-of-life and IBS symptoms: a double-blind, randomised, placebo-controlled study. Beneficial Microbes, 9 (5), 697–706. https://pubmed.ncbi.nlm.nih.gov/29888656/ (B)
  16. Pugh, J. N., Sage, S., Hutson, M., Doran, D. A., Fleming, S. C., Highton, J., Morton, J. P., & Close, G. L. (2017). Glutamine supplementation reduces markers of intestinal permeability during running in the heat in a dose-dependent manner. European Journal of Applied Physiology, 117 (12), 2569–2577. https://pubmed.ncbi.nlm.nih.gov/29058112/ (C)
  17. Sevastiadou, S., Malamitsi-Puchner, A., Costalos, C., Skouroliakou, M., Briana, D. D., Antsaklis, A., & Roma-Giannikou, E. (2011). The impact of oral glutamine supplementation on the intestinal permeability and incidence of necrotizing enterocolitis/septicemia in premature neonates. The Journal of Maternal-Fetal & Neonatal Medicine: The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 24 (10), 1294–1300. https://pubmed.ncbi.nlm.nih.gov/21463215/ (B)
  18. Wu, K.-L., Rayner, C. K., Chuah, S.-K., Changchien, C.-S., Lu, S.-N., Chiu, Y.-C., Chiu, K.-W., & Lee, C.-M. (2008). Effects of ginger on gastric emptying and motility in healthy humans. European Journal of Gastroenterology & Hepatology, 20 (5), 436–440. https://pubmed.ncbi.nlm.nih.gov/18403946/ (B) 
  19. Yasukawa, Z., Inoue, R., Ozeki, M., Okubo, T., Takagi, T., Honda, A., & Naito, Y. (2019). Effect of Repeated Consumption of Partially Hydrolyzed Guar Gum on Fecal Characteristics and Gut Microbiota: A Randomized, Double-Blind, Placebo-Controlled, and Parallel-Group Clinical Trial. Nutrients, 11 (9). https://pubmed.ncbi.nlm.nih.gov/31509971/ (C)
  20. Zhou, Q., Verne, M. L., Fields, J. Z., Lefante, J. J., Basra, S., Salameh, H., & Verne, G. N. (2019). Randomised placebo-controlled trial of dietary glutamine supplements for postinfectious irritable bowel syndrome. Gut, 68 (6), 996–1002. https://pubmed.ncbi.nlm.nih.gov/30108163/ (B)