Tx options in IBS-C

Misdxed functional bowel disorder.  Obsticle is lack of good available therapy.

IBS – Dx of exclusion till recently. No biochemical marker. No structural findings.

Sx based 3 criteria

1.       Recurrent abd pain or discomfort for 3days / months for the last 3 months.

2.       Sx improved by defication

3.       Change of form of the stool or change of frequency.

Sx started 6 months before the dx.

Additional helpful sx - Abnormal frequency, 3 BM /d. Imcomplete evacation, bloating .

R/o other problems: Unexplained wt loss, GI bleed, Nocturnal diarrhea, progressive unrelenting pain.

No single biological marker to dx IBS.

Cornerstone of tx is pt clinician relationship.

PCP – tends to be less severe pt

Specialists – tends to be severe patients.

Assessment

Key questions – why bothering? Why decided to interact with clinician if it has been chronic?

Try to find a trigger. Life style changes.

Pt should be empowered to take a role.

Use diary in my patients.

Premenstrual and menstrual

Tx

1.       Reassurance

2.       Validate the sx real not imagining.

3.       Trigger avoidance - food

4.       Diet/exercise/stress/medications alleviate patients sx. Increase fiber intake(20-30g/d). Start c low dose because fiber causes bloating.  

5.       Probiotic use for constipation sx.

6.       Exercise/yoga.

7.       Behavioral tx.

Pharmacological tx options

1.       Motility bulking agent, osmotic laxatives, chloride channel activator, SSRIs

IBS-C (Constipation)

1.       Start with Chloride channel activator – Lubiprostone (Amitiza, Sucampo/ Takeda) – opens up chloride channel in the intestine. Twice likely to achieve then placbo.  Chloride channel connects the space in the body. Chloride goes in to GI tract and Na follows and then water follows into the intestine, 8mcg BID,  24mcg BID used for women >18.

2.       Bulking agents – improve stool form but not global sx relief.

3.       Osmotic agents – lactulose, improve stool form and frequency, does not improve overall sx.

4.       SSRI – especially if pt has depression.

IBS-D (diarrhea)

1.       Use antispasmodic,

2.       No broad spectrum abx.

3.       5HT4 receptor agonist – tegaserod,  pulled out from the market by FDA due to increased cardiac AE and now the use is restricted to life threatening condition only.

4.       Loperamide, Studies are being undertaken.

Biggest challenging in dealing with IBS patients.

1.       Life long chronic disorder.

2.       No cure.