Post on 15-Oct-2020
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Irritable Bowel Syndrome
1Supported by educational grants from Salix, a division of Valeant Pharmaceuticals North America LLC, and Actavis.Sponsored by Integrity Continuing Education, Inc.
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William Sonnenberg, MDPast President, Pennsylvania Academy of Family Physicians
Clinical Assistant Professor Family and Community MedicinePenn State College of Medicine
Private Practice, Titusville, Pennsylvania
Faculty Affiliation
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The speaker has no conflict of interest, financial agreement, or working affiliation with any group or organization.
This session will include discussion of unapproved or investigation uses of products or devices.
Faculty Disclosures
Supported by educational grants from Salix, a division of Valeant Pharmaceuticals North America LLC, and Actavis.
This Session is Sponsored by Integrity Continuing Education, Inc.
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Complete Session Pre- and Post-Test Complete Online Session Evaluation at End of Sessionhttps://www.surveymonkey.com/r/Nov19_1515_Sonnenberg
**Links found in Event App
Reminder…
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Recognize the significant and pervasive impact of irritable bowel syndrome (IBS) on patients, families, and caregivers
Utilize evidence-based guidelines and available diagnostic tools to facilitate the timely and accurate diagnosis of IBS in patients with diarrhea
Evaluate the efficacy and safety of newer treatments for irritable bowel syndrome with diarrhea (IBS-D)
Learning Objectives
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Disease Overview
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Epidemiology of IBS
• 10-20% in developed countries
• 1.5 times more likely in women
• Peak prevalence 20 – 39 years of age
• More common in lower socioeconomic populations
– <$20,000 per year – 8% - 15%
– >$75,000 per year – 3% - 5%
Agarwal N et al. Gastroenterol Clin North Am. 2011;40(1):11-19.
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Definition – Rome IV Criteria
Sx onset ≥6 months prior to diagnosis
Recurrent abdominal pain, on average, ≥1 day/week in the last 3 months with ≥2 of the following:– Related to defecation
– Associated with a change in stool frequency
– Associated with a change in stool form (appearance)
Lacy BE et al. Gastroenterology. 2016.
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Risk Factors
• First degree relatives
– 3X risk
• Hx of sexual abuse
• Anxiety or depression
Malone, MA. Primary Care: Clinics in Office Practice. 38:3
Saito YA et al. Neurogastroenterol Motil. 2008;20(7):790-797.Drossman DA Eur J Gastroenterol Hepatol. 1997;9(4):327-330.Fond G et al. Eur Arch Psych Clin Neurosci. 2014;264(8):651-660.
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Problems
• Lower work productivity
• More physician visits
• More diagnostic tests
• More hospitalizations
• 50% higher health care costs
• 25% - 50% referrals to Gastroenterologists
Locke GR III. Gastroenterol Clin North Am. 1996;25(1):1–19.
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IBS and Employment
IBS Patients: Their illness experience and unmet needs, International Foundation for Functional Gastrointestinal Disorders (IFFGD); 2009.
30% with severe IBS symptoms reported being jobless vs only 5% of those with mild symptoms
12.80%
17.30%
69.9%
Patients with IBS joblessdue to health
Patients with IBS joblessnot due to health
Patients with IBScurrently working
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Lifestyle
• 14 hours of lost productivity per week
• One of top 3 reasons for absenteeism
• Avoid eating out
• Need to be near restrooms
Agarwal N et al. Gastroenterol Clin North Am. 2011;40(1):11-19.
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Surgery Issues
• Women with IBS have 4x more organ surgery
• Triple cholecystectomies
• 25% of colonoscopies under age 50
• Surgeries increase visceral sensitivity
Gut. 2007 May; 56(5): 608–610.
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Psychiatric Associations
• 2/3 of tertiary center patients have psychiatric issues
– Anxiety
– Depression
– PTSD
• 12% history of rape in severe disease
Talley NJ,et al. . Gut. 1998;42:47-53Creed F et al. Psychosom Med. 2005;67(3):490–499
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Patient Misconceptions Regarding Natural History of IBS
72.7 % 70.7 % 67.3 %
57.7 %
0
20
40
60
80
100
Develop colitis Developmalnutrition
Requiresurgery
Developcancer
Patie
nts
eith
er in
agr
eem
ent
or u
nsur
e (%
)
Halpert A, et al. Am J Gastroenterol. 2007;102(9):1972-1982.Halpert A, et al. Dig Dis Sci. 2010;55(2):375-383.
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IBS-D is Associated with Lower Disease-Specific QOL vs IBS-C
Singh P, et al. World J Gastroenterol. 2015;21(26):8103-8109.
IBS-QOL subscaleIBS-C
(n = 54)IBS-D
(n = 56)IBS-M
(n = 121) P-valueInterference with activity 82.3 59.6 61.6 < .001
Social reaction 80 59.6 61.6 .0082
Food Avoidance 61.1 45 47.2 .0203
Relationships 84.7 75.4 73.3 .0304
Dysphoria 69.2 57.1 58 .06
Health worry 64.3 60.9 57.3 .28
Sexual 73.9 74.6 68.8 0.5
Body Image 69.2 66 64.9 .631
Total 74.5 61.6 63 .0105
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Screening and Diagnosis
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Clinical presentation:– Recurrent abdominal pain and periods of loose stools (symptoms present
since patient’s early 20’s)– Increasing in frequency and severity of attacks over the past
6 months– Stools are frequently watery (occasionally with mucus, but without blood) – Bowel movements 4 to 7 times per day and not awakening her– Abdominal pain
• Associated with bloating and gas• Exacerbated by eating• Relieved with defecation
– Weight loss of 9 lb over the past 3 to 4 months
Case Study #1: 40-year-old woman
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Vital signs– HR: 97 bpm– RR: 18 breaths/min– BP: 126/82 mm Hg
CV and pulmonary exam:– Normal
Abdominal exam:– Abdomen flat, bowel sounds normal– Tympany in the upper-left quadrant– No organomegaly – Mild generalized tenderness
Case Study #1: Physical Exam
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Individual symptoms have limited accuracy
Alarm features are crucial for guidance
Role of testing
Recommended diagnostic tests
Case Study Discussion
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Presentation
• Recurrent and episodic pain
• Crampy
• Worse with stress
• Relief with defecation
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Loose/frequent stools Constipation Bloating Abdominal cramping, discomfort, or pain Symptoms:
– Brought on by food intake/specific food sensitivities– Dynamic over time (change in pain location, change
in stool pattern)
Typical Features of IBS
Brandt LJ, et al. Am J Gastroenterol. 2009;104(suppl 1):S1-S35.
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Bristol Stool Scale
Type 1 Separate hard lumps
Type 2 Sausage‐shaped but lumpy
Type 3 Like sausage but, surface cracks
Type 4 Like smooth sausage, smooth and soft
Type 5 Soft blobs with clear‐cut edges
Type 6 Fluffy pieces with ragged edges, mushy stool
Type 7 Watery, liquid
Available at: http://bowelcontrol.nih.gov/Bristol_Stool_Form_Scale_508.pdf
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Bristol Stool Scale
Type 1 Separate hard lumps
Type 2 Sausage‐shaped but lumpy
Type 3 Like sausage but, surface cracks
Type 4 Like smooth sausage, smooth and soft
Type 5 Soft blobs with clear‐cut edges
Type 6 Fluffy pieces with ragged edges, mushy stool
Type 7 Watery, liquid
Available at: http://bowelcontrol.nih.gov/Bristol_Stool_Form_Scale_508.pdf
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Other GI Symptoms
Dyspepsia
Nausea
Noncardiac chest pain
Bloating
Flatulence
Lump in throat
Belching
Acid reflux
Dysphagia
Early satiety
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Altered Bowel Habits
Mixed
Presentation
Patients migrate over time, mostly to mixed
Brandt LJ, et al. Am J Gastroenterol. 2009;104(suppl 1):S1-S35.
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Red Flags for Something Else
• Symptoms– Nocturnal pain
– Rectal bleeding
– Weight loss
• Labs– Anemia
– IBD marker (calprotectin)
• Other– Recent ABX therapy
• Demographic– Onset age > 50– Male
• Family History– Celiac disease– Colorectal cancer– Inflammatory bowel disease– Ovarian cancer
• Physical Exam– Abdominal mass
Brandt LJ, et al. Am J Gastroenterol. 2009;104(suppl 1):S1-S35.
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Differential of IBS
Hyperthyroidism hypothyroidism Infection
– Giardia, amoeba, HIV, bacterial overgrowth
Inflammatory bowel disease
Ischemic colitis Lactose intolerance
Carcinoid Celiac disease Colorectal cancer Diverticular disease Drug use
– Opioids
– CCB
– antidepressants
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Routine diagnostic testing NOT recommended for patients with typical symptoms and no alarm features
Serologic screening for celiac sprue Recommended for patients with IBS-D and IBS-M
Lactose breath testing Recommended if lactose maldigestion persists despite dietary modification
Breath testing for SIBO Insufficient data to recommend
Routine colonic imaging NOT recommended for patients < 50 years of age with typical IBS symptoms and no alarm features
Colonoscopic imaging Recommended for IBS patients with alarm features and those > 50 years of age
Random biopsies Consider to rule out microscopic colitisif colonoscopy is performed
ACG Guideline Recommendations for Diagnostic Testing*
*CBC, serum chemistries, thyroid function studies, stool for ova and parasites, abdominal imaging.ACG, American College of Gastroenterology; CBC, complete blood cell count; SIBO, small intestine bacterial overgrowth.
Brandt LJ, et al. Am J Gastroenterol. 2009;104(suppl 1):S1-S35.
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Consider
– CBC, ESR or CRP, fecal calprotectin
– Celiac panel
All patients do not require all testing
No role for routine colonoscopy
Rome IV: Limited Diagnostic Testing
Mearin F, Lacy BE et al. Gastroenterology. 2016;150:1393-1407
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Celiac Disease
• 36% of patients with celiac disease initially diagnosed with IBS
• 3-5% of IBS patients really have celiac disease
• Screen diarrhea-predominant or mixed
• IgA tTg and IgA screen
Green PH. Gastroenterology. 2005;128(4 suppl 1):S74–S78Am J Gastroenterol. 2009 Jun; 104(6): 1587–1594.
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Pathogenesis of IBS
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Factors
Altered GIReactivity
VisceralHypersensitivity
Inflammation
Post infection
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Altered GI Reactivity
• Prolonged gastro-colonic response to test meals or sham feedings
• Prolonged colonic transit times with constipation and distension compared to constipation without distension
• ↓ or ↑ transit time with diarrhea-predominant
Malone, MA. Primary Care: Clinics in Office Practice. 38:3
Agrawal A, et al. Am J Gastroenterol. 2009;104(8):1998.
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Visceral Hypersensitivity
• Rectal distension produces more cortical activity than controls
• More bloating complaints with same gas
Malone, MA. Primary Care: Clinics in Office Practice. 38:3
World J Gastroenterol. 2003 Jun;9(6):1356-60
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Inflammation
• Increased inflammatory cells in colon and ileal mucosa
• Alteration in fecal microflora
Malone, MA. Primary Care: Clinics in Office Practice. 38:3
Barbara, G et al. Gut 2000;51:i41-i44
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Postinfectious
• 6-fold increase in IBS for 2-3 years post-infection
• 5% - 32% of IBS pts develop symptoms post-infection
• About twice as common in females
• Resolves ½ time in 6-8 yearsMalone, MA. Primary Care: Clinics in Office Practice. 38:3
World J Gastroenterol. 2009 Aug 7; 15(29): 3591–3596Spiller R, et al. J Neurogastroenterol Motil. 2012;18(3):258-268.
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Serotonin
Reduced in constipation predominant
Increased in diarrhea
predominant
Dunlop SP et al. Clin Gastroenterol Hepatol. 2005;3(4):349–357
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Comorbidities Associated with IBS
Lackner JM, et al. Clin Gastroenterol Hepatol. 2013;11(9):1147-1157.
91% of patients with IBS reported ≥1 comorbidity
Average number reported was 5 (1 mental, 4 physical)
Anxiety, depression, back pain, agoraphobia, tension headache, insomnia were associated with greater illness and symptom burden
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Meds That Worsen IBS
Over-the-Counter Antihistamines
Calcium Iron
Magnesium NSAIDs Wheat bran
Prescription Antibiotics
Antidepressants Antiparkinsonian drugs
CCBs Diuretics Metformin
Opioids
Chey WD et al. JAMA. 2015;313(9):949-958.
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Nonpharmacological Management of IBS
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Dietary Advice
• Avoid excess caffeine, chocolate, alcohol, fatty foods
• Identify food triggers
• Smaller, more frequent meals
• More fiber, fruits, vegetables
• Allow enough time for meals
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Fermentable Carbohydrates
• FODMAPS – Fermentable oligo-, di-, monosaccharaides and polyols
• Short chained CHO not normally absorbed
• Produces gas, bloating, cramping, diarrhea
• Several trials show benefit of restriction
Staudacher HM et al. J Hum Nutr Diet. 2011;24(5):487-495.
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Examples of Fermentable Foods
Dairy Milk, yogurt, soft cheese
FruitsApples, avocados, peaches, pears, watermelons, nectarines
Grains Rye, Wheat
Legumes Lentils, peas
VegetablesArtichokes, asparagus, beets, Brussels sprouts, broccoli, cabbage, cauliflower, garlic, onions
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Randomized Trial
30 IBS pts, 8 controls
3 weeks on regular “Australia diet” and 3 weeks on low-FODMAP diet
Mean IBS scored of 36
– Declined to 23 on low-FODMAPS
– Increased to 45 on regular diet
No change with controls GastroenterologyVolume 146, Issue 1 , Pages 67-75.e5, January 2014
Halmos EP et al. Gastroenterology. 2014;146(1):67-75.e65.
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Fiber?
• Cochrane review, 12 RCT, 621 patients
– No benefit for soluble or insoluble fiber
– Included pain, global assessment or symptom score
Ruepert L et al. Cochrane Database Syst Rev. 2011;(8):Cd003460.
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Fiber?
• Another meta-analysis, 17 RCTs
– Global IBS Sx improved. RR 1.33
– C-IBS improved most. RR 1.21
– Soluble fiber. RR 1.55
• Pysllium, ispaghula, calcium polycarbophil
– Insoluble fiber. RR 0.89
• Corn, wheat branBijkerk CJ et al. Aliment Pharmacol Ther. 2004;19(3):245-251.
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Fiber, Meta-Analysis 17 RCTs
Relative Risk
Improvement of global symptoms 1.33
IBS‐Constipation most improved 1.21
Soluble FiberPysllium, ispaghula, calcium polycarbophil
1.55
Insoluble FiberCorn, wheat bran
0.89
Bijkerk CJ et al. Aliment Pharmacol Ther. 2004;19(3):245-251
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Soluble Insoluble
• Attracts water and turns to gel during digestion
• Slows digestion• Sources:
− Oat bran, barley, nuts, seeds, beans, lentils, and peas
− Some fruits and vegetables
− Psyllium (ispaghula)
• Adds bulk to the stool • Decreases GI transit time• Sources:
− Wheat bran, vegetables, and whole grains
Soluble vs Insoluble Fiber
Lembo A, et al. (2010). Constipation, Elsevier Saunders
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Gluten?
• 34 patients with IBS, Celiac disease excluded – controlled on gluten-free diet
• Two slices toast and one muffin given to rechallenge group
– 68% of gluten not adequately controlled
– 40% of gluten-free not adequately controlled
• Less GI symptoms and fatigue
Biesiekierski JR et al. Am J Gastroenterol. 2011;106(3):508-514.
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Gluten?
Biesiekierski JR et al. Am J Gastroenterol. 2011;106(3):508-514.
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Probiotics
• Weak RCTs
• Reduce pain, symptoms, flatulence
• No difference between Lactobacillus, Streptococcus, and Biffdobacterium.
– Doses and magnitude of effect unknown
Moayyedi P et al. Gut. 2010;59(3):325-332.
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Bifidobacterium infantis Capsule Reduces Symptoms of IBS
*P<0.03 vs placebo
Whorwell PJ et al. Am J Gastroenterol. 2006;101(7):1581-1590.
-0.29-0.33
-0.29
-0.45-0.39
-0.36
-0.6
-0.4
-0.2
0
Abdominalpain/discomfort
Bloatingdistension Urgency
Incompleteevacuation Straining Overall
Mea
n D
iffer
ence
vs
Plac
ebo
(%)
*
**
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Exercise and IBS
• RCT of 102 patients
– 8% fewer IBS Sx in control group
– 23% fewer IBS Sx in exercise group
Hint: Never vote against exercise, 8 hours of sleep, or vitamin D
Johannesson E et al. Am J Gastroenterol. 2011;106(5):915-922.
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Exercise and IBP
Johannesson E et al. Am J Gastroenterol. 2011;106(5):915-922
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Peppermint Oil
• 4 studies, 392 patients
• Persistent symptoms
– 26% treated
– 65% placebo
• NNT 2.5
• Avoid in GERD
Ford AC et al. BMJ. 2008;337:a2313.
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Prunes; Good Run for the Money
High in fiber and sorbitol
8 week RCT, 6 prunes per day compared to psyllium (11 g/day) taken bid
– 40 patients with chronic constipation
– More CSBMs/week (3.5 v. 2.80)
– Softer stools (3.2 v. 2.8 on Bristol scale)
– Better than psyllium
Attaluri A, et al. Aliment Pharmacol Ther. 2011;33(7):822-828
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Pharmacologic Treatment Options
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Centrally Acting Agents
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Psychological Therapy
• Effective
– Psychotherapy
– Relaxation and stress therapy
• Not proven
– Hypnotherapy
– Acupuncture
Wilkins T et al. Am Fam Physician. 2012;86(5):419-426..
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Cognitive Behavioral Therapy
Meta-analysis of 17 RCTs
50% improvement in Sx
NNT 2
Hint: CBT is always right too
Thought
BehaviorEmotion
Lackner JM et al. J Consult Clin Psychol. 2004;72(6):1100-1113.
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Antidepressants
Meta-analysis of 17 RCTs trials
– RR of symptoms 0.62
– NNT 4
TCAs cause constipation – use in IBS-D
SSRI’s cause diarrhea – use in IBS-C
Start with low doses
Ford AC et al. Am J Gastroenterol. 2014;109(9):1350-1365; quiz 1366.
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Medications Targeting Diarrhea
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Antidiarrheals
• Lomperamide, only one with RTC trials
– ↓ intestinal transit
– ↑ ion and water absorption
• ↓ stool frequency, better consistency
• Doe not cross blood brain barrier
• No help with pain
Lesbros-Pantoflickova D et al. Aliment Pharmacol Ther. 2004;20(11–12):1253–1269.
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Antispasmodics
• Hyoscyamine, and dicyclomine
• 29 RCTs significant heterogeneity
• Improves pain, global assessment, symptom score
• Side effects; dry mouth, dizziness, blurred vision
• Avoid in elderly
Ruepert L, et al. Cochrane Database Syst Rev. 2011(8):CD003460
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Bile Acid-Binding Agents
Bile acid diarrhea factor in 1/3 of IBS-D
Olesevelam, obeticholic acid, colestipol, and cholestyramine
Improve frequency and form
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Serotonergic agent
Women with severe IBS-D
Ischemic colitis,
– Withdrawn 2000, reinstated 2002 with restrictions
Improves stool consistency, urgency, bloating
No help with pain
Alosetron, Overview
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Infrequent, but serious GI adverse reactions (eg, ischemic colitis, serious complications of constipation) reported; some have resulted in hospitalization and, rarely, blood transfusion, surgery, or death
Prescribing physicians must be enrolled in Prescribing Program for Lotronex
Indicated only for women with severe IBS-D that have not responded adequately to conventional therapy
Discontinue immediately in patients who develop constipation or symptoms of ischemic colitis; do not resume in those who develop ischemic colitis
Alosetron: Black Box Warnings
Lotronex(R) [package insert]. San Diego, CA: Prometheus Laboratories Inc.; 2014.
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Mu and kappa opioid receptor agonist, delta receptor antagonist
Minimal bioavailability
Reduces visceral hypersensivity
Decreases transit time
Eluxadoline, Overview
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Eluxadoline: Sustained Reduction of IBS-D Symptoms over 6 Months
Eluxadoline treatment resulted in more patients reporting a ≥30% reduction in abdominal pain score and a stool-consistency score <5 on ≥50% of the days†.
†Represents composite primary efficacy end point*P<.0; ** P<.001Lembo AJ, et al. N Engl J Med. 2016;374(3):242-253.
19.0 20.2 19.523.430.4
26.729.332.7 31.0
0
20
40
60
80
100
IBS-3001 Trial IBS-3002 Trial Pooled Data
Patie
nts
(%)
Placebo Eluxadoline, 75 mg Eluxadoline, 100 mg
N=427 N=426 N=427 N=381 N=382 N=382 N=808 N=806 N=809
** ****
***
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Most commonly observed AEs:
Pancreatitis developed in 5 (2 in the 75 mg group and 3 in the 100 mg group) of the 1666 patients in the safety population (0.3%)
Adverse Effects of Eluxadoline
AE Placebo (%)
75 mg Eluxadoline
(%)
100 mg Eluxadoline
(%)Constipation 2.5 7.4 8.6
Vomiting 1.4 8.1 7.5
Abdominal pain 4.1 5.8 7.2
Lembo AJ, et al. N Engl J Med. 2016;374(3):242-253.
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Avoid in
• Constipation (It’s for IBS- constipation)
• Pancreatitis
• Bile duct obstruction
• Sphincter of Oddi problems (causes spasm)
Eluxadoline, Precautions
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Rifaximin: Sustained Reduction of Symptoms Over 12 Weeks
Pimentel M, et al. N Engl J Med. 2011;364(1):22-32.
TARGET 1 and 2 Trials
Two weeks of treatment with rifaximin resulted in a greater percentage of patients achieving adequate relief of global IBS symptoms.
Patie
nts
with
Ade
quat
e R
elie
f (%
)
0 2 4 6 8 10 12Week
6050403020100
14-DayDouble-
blind treatment
phase
10-Wk follow-up(no study medication)
P=0.001
Rifaximin
Placebo
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Rifaximin Improves Symptoms in Recurrent IBS-D
TARGET 3 Trial
1st Repeat Treatment 2nd Repeat Treatment
EndpointRifaximin(n=328)
Placebo(n=308) P Value
Rifaximin(n=328)
Placebo(n=308) P Value
Urgency 48.5% 39.6% .0251 46.8% 38.5% .0355
Bloating 50.3% 42.2% .0345 47.1% 35.0% .0017
Abdominal pain 53.0% 43.8% .0212 52.5% 44.9% .0549
Stool consistency 45.1% 37.0% .0241 45.1% 38.5% .0799
TARGET 3, Targeted, Nonsystemic Antibiotic Rifaximin Gut-Selective Evaluation of Treatment for Non-C IBS
Chey WD, et al. Gastroenterology. 2015;148(4):S-69.
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Safety and Tolerability of Rifaximin
URI, upper respiratory infection; UTI, urinary tract infection
Schoenfeld P, et al. Alimentary Pharmacology & Therapeutics. 2014;39(10):1161-1168.
0.0
1.0
2.0
3.0
4.0
5.0
% P
atie
nts
expe
rienc
ing
AE
Placebo (N=829) Rifaximin (N=624)
GI-ASSOCIATED AES INFECTION-ASSOCIATED AEs
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Medication Targeting Constipation
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OTC Laxatives
• Polyethylene glycol
– Improve stool frequency
– No help with pain compared to placebo
Am J Gastroenterol. 2013 Sep;108(9):1508-15
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Improve stool frequency and pain
Increase chloride and fluid secretion
May take 9 weeks to improve pain
Linacolitide
Am J Gastroenterol 2012; 107:1702–1712
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Stimulates fluid secretion
Nausea, give with food
Lubiprostone
80
17.9
10.1
0
5
10
15
20
25
30
35
40
45
50
Lubiprostone Placebo
Lubiprostone for IBS-C
Alimentary Pharmacology & TherapeuticsVolume 29, Issue 3, pages 329-341, 4 NOV 2008
Percent Improvement
Over 12 weeks
81
Long-term Management
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82
Patient-identified Factors that Contribute to Disease Burden
61.5
53.5
50.2
49.6
45.4
42.2
39.2
39
27.3
10.8
0 10 20 30 40 50 60 70
Social limitationsCannot leave home
Work/school limitationsLimitations in thinking
Trouble sleepingNausea
Limitations in home activitiesPoor quality of life
IncontinenceOther troubles
Respondents (%)
IBS Patients: Their illness experience and unmet needs, International Foundation for Functional Gastrointestinal Disorders (IFFGD); 2009.
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Patient Education and Support
Providing education on
IBS-D and options for treatment
Setting patient
expectations
Managing medication side effects
Ensuring treatment adherence
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International Foundation for Functional Gastrointestinal Disorders – http://www.iffgd.org/
Institute for Functional Medicine– https://www.functionalmedicine.org/
Irritable Bowel Syndrome Association– http://www.ibsgroup.org/ibsassociation.org/
IBS Page– http://ibspage.com/
Additional IBS Resources
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IBS-D is a highly prevalent functional bowel disorder that imposes a tremendous burden due to its pervasive negative impact on the physical, social, and economic well-being of affected individuals
Diagnosis is based upon a thorough clinical history and physical examination, in conjunction with application of the Rome IV criteria
Treatment options include several pharmacologic and nonpharmacologic strategies, which have demonstrated efficacy at reducing symptoms of IBS-D and improving patient QOL
Long-term management should be individualized and include education and support to foster patient understanding of the disease, ensure treatment adherence, and guide therapeutic expectations
Summary
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The End; Out of Paper
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Complete Session Pre- and Post-Test Complete Online Session Evaluation at End of Sessionhttps://www.surveymonkey.com/r/Nov19_1515_Sonnenberg
**Links found in Event App
Reminder…
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88
Q & A
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Thank You!
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Management of IBS-D
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Goals of Treatment
Improve individual symptoms
Ameliorate global
symptoms
Prevent complications
Reduce impact on the individual
and society
Lacy BE, et al. Therapeutic Advances in Gastroenterology. 2009;2(4):221-238.
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Medical history– Diagnosed with traveler’s diarrhea 2 years ago by PCP– Since that time, persistent GI symptoms, including bloating, cramping, and
loose, watery stools (3-5 times per day)
– Bowel function was normal prior to the trip
Case Study #2: 32-year-old man
PCP, primary care provider.
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Treatment history– Increased fiber intake exacerbates symptoms– Antidiarrheal medications, useful for fecal urgency and diarrhea, fail to
relieve pain and bloating
– Unresponsive to anticholinergics
Additional comments– Patient is frustrated with the lack of effective symptom management
Case Study #2 (cont’d)
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Lack of symptom control/response to conventional therapies is common
IBS-D in men vs women Precipitation of disease by infection Newer pharmacologic management strategies
Case Study Discussion
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Overview
• Goal of symptom relief and quality of life
• Patient-physician interaction
• High-quality trials difficult
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Summary of Treatments
• Selective C-2 chloride channel activators
• Antidepressants• Complementary and alternative
therapies• 5-HT3 antagonists• 5-HT4 agonists
• Exercise• Fiber• OTC laxatives• Antidiarrheals• Probiotics• antibiotics