LETTERS TO THE EDITORS | 445

hypersensitivity, thus suppressing abdominal pain. This hypothetical REFERENCES

algorithm is reasonably consistent with the research of Schumann
1. Schumann D, Langhorst J, Dobos G, Cramer H.Randomised clinical
et al. Therefore, I would suggest the measurement of intestinal
trial: yoga vs a low-FODMAP diet in patients with irritable bowel
blood flow as increased by yoga. syndrome. Aliment Pharmacol Ther. 2018;47:203-211.
2. Kanazawa M, Hongo M, Fukudo S. Visceral hypersensitivity in
irritable bowel syndrome. J Gastroenterol Hepatol. 2011;26:119-121.
ACKNOWLEDGEMENTS 3. Major G, Pritchard S, Murray K, et al. Colon hypersensitivity to dis-
tension, rather than excessive gas production, produces carbohy-
Declaration of personal interests: Uno Y was granted a trademark of drate-related symptoms in individuals with irritable bowel syndrome.
low-FODMAP diet from the Japan Patent Office. Gastroenterology. 2017;152:124-133.
4. Barbara G, Stanghellini V, de Giorgio R, et al. Activated mast cells in
proximity to colonic nerves correlate with abdominal pain in irritable
FUNDING INFORMATION bowel syndrome. Gastroenterology. 2004;126:693-702.
5. Ravnefjord A, Pettersson M, Rehnstro € m E, Martinez V. Acute colonic
None. ischaemia in rats results in long-term structural changes without
alterations of colonic sensitivity. Int J Exp Pathol. 2008;89:476-489.
6. Xu XJ, Zhang YL, Liu L, Pan L, Yao SK. Increased expression of nerve
ORCID growth factor correlates with visceral hypersensitivity and impaired
gut barrier function in diarrhoea-predominant irritable bowel syn-
Y. Uno http://orcid.org/0000-0003-2281-7487 drome: a preliminary explorative study. Aliment Pharmacol Ther.
2017;45:100-114.
This article is linked to Schumann et al and Schumann and Cramer 7. Andersson PO. Vascular control in the colon and rectum. Scand J
Gastroenterol. 1984;93:65-78.
papers. To view these articles visit https://doi.org/10.1111/apt.
8. Vinay AV, Venkatesh D, Ambarish V. Impact of short-term practice
14400 and https://doi.org/10.1111/apt.14457. of yoga on heart rate variability. Int J Yoga. 2016;9:62-66.
9. Uno Y. Low-FODMAP diet for exercise-induced gastrointestinal syn-
drome. Aliment Pharmacol Ther. 2017;46:1021-1022.
Y. Uno 10. Costa RJS, Snipe RMJ, Kitic CM, Gibson PR. Systematic
review: exercise-induced gastrointestinal syndrome-implications for
Office Uno Column, Kakogawa, Hyogo, Japan
health and intestinal disease. Aliment Pharmacol Ther. 2017;46:
Email: yoshiharu333@hotmail.com 246–265.

DOI: 10.1111/apt.14457

Letter: irritable bowel syndrome—how a low-FODMAP diet

or yoga might help. Authors’ reply
EDITORS, vasoconstriction.7 Shifting from a mode of fight and flight driven by
We read with interest the letter of Dr Yoshiharu Uno, in response to the sympathetic nervous system to a regulated state of the parasym-
our research on yoga vs a low-FODMAP diet in patients with the pathic nervous system could surely increase the blood flow to the
1,2
irritable bowel syndrome (IBS). Interestingly, as mentioned by Dr intestines. Furthermore, deep belly breathing during the asana prac-
Uno, the results in the yoga group might not be solely psychological tice might further enable increased blood flow to the intestinal
but could more likely be due to a shift in the autonomic nervous organs. Under the aspect of the involvement of a decreased intesti-
system. In fact, increasing parasympathic activity and decreasing nal blood flow in the pathology of IBS, the results in the yoga group
sympathetic activation has been proposed as a major mechanism of support recent evidence in multiple studies, suggesting that exercise
yoga in reducing stress and improving somatic conditions.3,4 Specifi- has a positive effect on IBS-associated symptoms.8,9
cally, yoga can activate the gamma amino-butyric acid (GABA) sys- In contrast to the presumed mode of action of the low-FODMAP
tem, the primary inhibitory neurotransmitter system, and thus diet, which is based on the reduction in the intraluminal gas and
increase parasympathetic nervous system, counteracting the stress- water content and thus reducing abdominal pain, the mode of action
3
induced activity of the sympathetic nervous system. of yoga on IBS might be partially explained as hypothesised by Dr
In line with this hypothesis, yoga can reduce sympathetic domi- Uno: an increased inflow of the intestinal arteries, thus decreasing
nance and lower anxiety, depression, and autonomic symptom scores abdominal pain even in the presence of high intestinal pressure.
in patients with irritable bowel syndrome.5,6 Therefore, including more objective measures such as heart rate vari-
The sympathetic nervous system exerts a predominantly inhibi- ability or intestinal blood flow in patients with IBS after yoga prac-
tory effect upon gastrointestinal blood flow via neurally mediated tice might be worthwhile.

© 2018 John Wiley & Sons Ltd

446 | LETTERS TO THE EDITORS

ACKNOWLEDGEMENTS 2. Schumann D, Langhorst J, Dobos G, Cramer H. Randomised clinical

trial: yoga vs a low-FODMAP diet in patients with irritable bowel syn-
The authors’ declarations of personal and funding interests are drome. Aliment Pharmacol Ther. 2018;47:203-207.
unchanged from those in the original article.2 3. Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of
yoga on the autonomic nervous system, gamma-aminobutyric-acid,
and allostasis in epilepsy, depression, and post-traumatic stress disor-
ORCID der. Med Hypotheses. 2012;78:571-579.
4. Cramer H. The efficacy and safety of yoga in managing hypertension.
D. Schumann http://orcid.org/0000-0003-3368-2522 Exp Clin Endocrinol Diabetes. 2016;124:65-70.
5. Kavuri VS, Malamud A, Raghuram N, et al. Remedial yoga module
H. Cramer http://orcid.org/0000-0002-3640-8046
remarkably improves symptoms in irritable bowel syndrome patients:
a 12-week randomized controlled trial. Eur J Integr Med. 2015;7:595-
LINKED CONTENT
608.
6. Schumann D, Anheyer D, Lauche R, Dobos G, Langhorst J, Cramer H.
This article is linked to Schumann et al and Uno papers. To view
Effects of yoga in the therapy of irritable bowel syndrome: a system-
these articles visit https://doi.org/10.1111/apt.14400 and https:// atic review. Clin Gastroenterol Hepatol. 2016;14:1720-1731.
doi.org/10.1111/apt.14433. 7. Browning KN, Travagli RA. Central nervous system control of gas-
trointestinal motility and secretion and modulation of gastrointestinal
functions. Compr Physiol. 2014;4:1339-1368.
8. Johannesson E, Ringstrom G, Abrahamsson H, et al. Intervention to
D. Schumann
increase physical activity in irritable bowel syndrome shows long-term
H. Cramer positive effects. World J Gastroenterol. 2015;21:600-608.
Department of Internal and Integrative Medicine, Faculty of Medicine, 9. Johannesson E, Simren M, Strid H, et al. Physical activity improves
Kliniken Essen-Mitte, University of Duisburg-Essen, Essen, Germany symptoms in irritable bowel syndrome: a randomized controlled trial.
Am J Gastroenterol. 2011;106:915-922.
Email: d.schumann@kliniken-essen-mitte.de
REFERENCES

1. Uno Y. Letter: irritable bowel syndrome—how a low-FODMAP diet or

yoga might help. Aliment Pharmacol Ther. 2018;47:444-445.

DOI: 10.1111/apt.14435

Letter: the safety of herpes zoster vaccination for patients

with inflammatory bowel disease being treated with anti-TNF
medications
EDITORS, interest was the development of HZ between 0 and 42 days after
We read with great interest the article “Safety of herpes zoster (HZ) HZ vaccine administration, confirmed by two independent reviewers
vaccination among inflammatory bowel disease (IBD) patients being who performed individual chart reviews. No cases of HZ were found
1 in this study population; however, the occurrence of HZ is not the
treated with anti-TNF medications.” This topic is relevant as
patients with IBD have an increased risk of HZ compared with the most relevant endpoint in this clinical context.
general population, which is further increased by immunosuppres- HZ results from the reactivation of the latent varicella-zoster
sion.2,3 Furthermore, data suggest that newly investigated Janus virus (VZV) which lies dormant in the dorsal root ganglia.9 VZV is
kinase inhibitors, small molecules that target intracellular cytokine characterized by a painless diffuse vesicular eruption often over mul-
4-7 tiple dermatomes, and can potentially progress to life threatening
signaling, accentuate HZ risk more than other immunosuppressors.
Vaccination with Zostavax II (Merck, Kirkland, Canada) is indicated in pneumonitis, hepatitis or encephalitis. In contrast, HZ is character-
IBD patients over 50 years of age.8 However, the timing of vaccina- ized by a painful vesicular rash confined to one or two unilateral
tion remains a debated question, considering the potential side contiguous dermatomes which can potentially cause debilitating
effects of administering a live-attenuated vaccine in an immunocom- post-herpetic neuralgia.10 The main concern with live-attenuated
promised patient on biologic. vaccination in immunocompromised individuals is the inability of the
In Khan et al’s article,1 the safety of HZ vaccination in patients altered immune system to contain the live vaccine strain virus, which
on anti-TNF agents was explored retrospectively. Data were may lead to localized or disseminated VZV infection. Thus, the
obtained from the Veterans’ Administration Pharmacy Benefits Man- potential complication of Zostavax in patients on anti-TNF agents is
agement and Corporate Data Warehouse database. The outcome of a VZV-like reaction rather than HZ, both similar disease entities but

© 2018 John Wiley & Sons Ltd