IBS – Primary Care Update - c.ymcdn.com€¦ · IBS – Primary Care Update Kendrick Che, DO...
Transcript of IBS – Primary Care Update - c.ymcdn.com€¦ · IBS – Primary Care Update Kendrick Che, DO...
IBS – Primary Care Update
Kendrick Che, DO February 18, 2017
Loma Linda University Medical Center Department of Gastroenterology
Learning objectives
• Identify recent diagnostic criteria for IBS (Rome IV).
• Recognize alarm symptoms that require more extensive workup.
• Discuss treatment options for different types of IBS.
IBS Trivia
• 12% primary care visits related to IBS (Top 10 reason)
• 30% GI visits IBS related (#1 reason) • Leading cause of missed work days (2nd to
common cold) • Affects 15-20% of general population • $10 billion direct costs (office visit, medications) • $20 billion indirect costs (absent work, reduced
productivity)
Gas is Good?
• Matt Whiteman Study from University of Exeter in UK – Hydrogen sulfide – Small quantity reverse mitochondrial damage – Final verdict still up in the air…
IBS Diagnostic Criteria
Rome IV Criteria
• Recurrent abdominal pain 1 day/week in last 3 months associated with 2 or more of the following: – Defecation – Change in stool frequency – Change in stool appearance
Manning Criteria
• Pain improve with defecation • More stools with onset of pain • Loose stools at onset of pain • Visible abdominal distention • Passage of mucus • Sensation of incomplete evacuation
Anti-vinculin and Anti-cdtB
• Anti-cdtB (cytolethal distending toxin B) – Toxin produced by Camylobacter jejuni
• Anti-vinculin – Vinculin – cytoskeletal protein required for neuron
migration
Pimental M PLoS One. 2015 May 13;10(5):e0126438
Anti-vinculin and Anti-cdtB
Pimental M PLoS One. 2015 May 13;10(5):e0126438
Bristol Stool Scale
IBS Subtypes
• Constipation – Bristol stool 1 or 2 • Diarrhea – Bristol stool 6 or 7 • Mixed - >25% abnormal stool constipation and
diarrhea
• BLOATING, GAS, DISTENTION
Differential Diagnosis
Alarm Signs
• GI bleeding • Nocturnal symptoms • Weight loss • Abnormal labs
– Anemia – Inflammatory markers – Electrolyte imbalance
• Age >50 • Family history
Non Pharmalogical Therapy
FODMAPS
• Fermentable Oligo-, Di-, Monosaccharides and Polyols – Association of food with symptoms – Especially gas and bloating, diarrhea – Improve overall symptoms compared to regular
diet
FODMAPS
FODMAPS
Courtesy of William Chey Advances in IBS 2016
Exercise
• Physical activity improves GI symptoms in IBS
• Study in 102 patients – Exercise vs control group – Significant improvement in IBS
Symptom Severity Score – No change in bloating or stool
quality
Johannesson E, et al. The American Journal of Gastroenterology 106, 915-922 (May 2011)
Psychological Therapy
• Cognitive behavioral therapy • Hypnotherapy • Group therapy
IBS-D
Workup
• Stool cultures – Giardia
• Rule out celiac disease • Colonoscopy
– Microscopic/collagenous colitis
• Medications • NSAIDS, metformin, PPI/H2 blockers, diuretics,
antihypertensive (beta blocker, ACEI)
Therapies
Courtesy of William Chey Advances in IBS 2016
OTC Therapy
• Loperamide (Imodium) – 45 minutes before meals – Improves diarrhea – No change for abdominal pain, bloating – Max 16mg/day
Rifaximin
• Minimally absorbed antibiotic • Inhibits bacterial protein synthesis • Modulation of intestinal microbiota
contributing to microscopic inflammatory process
Rifaximin
Courtesy of William Chey Advances in IBS 2016
Rifaximin TARGET 3
Rifaximin TARGET 3
Courtesy of William Chey Advances in IBS 2016
Rifaximin
Ondansetron
Courtesy of William Chey Advances in IBS 2016
Eluxadoline (Viberzi)
• μ- and κ- opioid receptor agonist • δ-opioid receptor antagonist • Minimal absorption • Binds to peripheral opioid receptors in GI tract
– Slowing GI motility – Decrease gut secretions
• Decrease sensitivity of afferent neurons (submucosa) – Reduce visceral hypersensitivity – Local gut effect – No CNS involvement
Eluxadoline (Viberzi)
Eluxadoline (Viberzi)
Eluxadoline (Viberzi)
*OATP (Organic anion transporting polypeptide) inhibitor: cyclosporine, gemfibrozil, rifampin
*
Workup
• Xray - retained stool – Sitz marker study – Anorectal dyssynergia
• Colonoscopy – Over age 50 – Any signs of obstruction
• Medications – Narcotics – Anticholinergic/antispasmotics – Calcium channel blockers
Therapies
Courtesy of William Chey Advances in IBS 2016
OTC Therapy
• Fiber (psyllium) – Cause gas
• Titrate dosing upward
– No improvement with bran
• Polyethylene glycol 3350 – Improves constipation – No effect on abdominal pain or bloating
Linaclotide (Linzess)
• Guanylate cyclase C receptor agonist – Increase intra and extracellular concentration of
cyclic GMP • Activate CFTR (cystic fibrosis transmembrane
conductance regulator) ion channel • Stimulate secretion of chloride and bicarbonate into
intestinal lumen • Increase fluid in intestine • Accelerate colonic transit
Linaclotide (Linzess)
Courtesy of William Chey Advances in IBS 2016
Linaclotide (Linzess)
Courtesy of William Chey Advances in IBS 2016
Linaclotide (Linzess)
Lubiprostone (Amitiza)
• Chloride channel activator in small bowel – Enhances chloride intestinal fluid secretion – Soften stool
Lubiprostone (Amitiza)
Courtesy of William Chey Advances in IBS 2016
Lubiprostone (Amitiza)
Courtesy of William Chey Advances in IBS 2016
Lubiprostone (Amitiza)
IBS - Mixed
Peppermint Oil (IBgard)
• Treat IBS-M and IBS-D • Active component L-
menthol – Anti-spasmotic – Anti-inflammation – Anti-bacterial – Serotonergic
• Triple coated release in small bowel
Cash BD, et al Dig Dis Sci. 2016 Feb;61(2):560-71
Cash BD, et al Dig Dis Sci. 2016 Feb;61(2):560-71
Peppermint Oil (IBgard)
Anticholinergics
• Reduce abdominal spasms and cramps • Reduce GI motility and hypersensitivity • Dicyclomine (Bentyl) • Hyoscyamine (Levsin) • Side effects
– Dry mouth – Constipation – Blurry vision – Urinary retention
Antidepressants
• TCA and SSRI • Reduce global IBS symptoms
and abdominal pain • TCA most used in IBS • SSRI increase bowel/colon
transit – Benefit in IBS-C
Antidepressants • Prescribing Approach
– TCA for IBS-D – SSRI for IBS-C and anxiety
• Start with low dose and titrate slowly every 1-2 weeks by response – Allow 4-8 weeks for full response
• Switch to different class or combine if not tolerated or ineffective
• Continue at minimum dose 6-12 months – May need long term therapy – Slow taper to prevent withdraw symptoms
Chey WD, et al. Gut Liver. 2011;5:253-266. Grover M, et al. Gastroenterol Clin N Am. 2011;40:183-206
Conclusions
• IBS is very common. • Diagnostic criteria includes chronicity. • Rule out real pathology. • Treatment guided by symptoms. • Include pharmalogical and non-pharmalogical
agents. • Listen, Reassurance, Guide.