irritable bowel syndrome...1 1 irritable bowel syndrome supported by educational grants from salix,...

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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


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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


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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.


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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


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


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


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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79

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.

83

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

89

Thank You!

90

Management of IBS-D

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91

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

irritable bowel syndrome...1 1 irritable bowel syndrome supported by educational grants from salix,...

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