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Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME March 2016 - Page 2/6 Enhanced Primary Care Pathway: IBS 1. Focused summary of IBS relevant to primary care Irritable bowel syndrome is a common symptom complex characterized by chronic abdominal pain and abnormal bowel function in absence of organic cause. These key features of IBS can be widely variable in severity and may remit and recur, often being affected by dietary factors and various stressors. Relief of abdominal discomfort after bowel movement is a defining feature. Bowel dysfunction includes frequent bowel movements, fecal urgency and even incontinence, altered stool form (hard/lumpy or loose/watery), incomplete evacuation, straining at stool, and passage of copious mucus. IBS is frequently associated with other gastrointestinal symptoms including bloating, flatulence, nausea, burping, early satiety, gastroesophageal reflux, and dyspepsia. Extra-intestinal symptoms also frequently occur in IBS patients including dysuria and frequent, urgent urination, widespread musculoskeletal pain, dysmenorrhea, dyspareunia, fatigue, anxiety, and depression. Diagnostic criteria for IBS (e.g. Rome IV) were developed for uniformity of patient recruitment in clinical trials. In clinical practice, such criteria only provide a framework for assessing patients with suspected IBS; indeed these criteria alone are far better for ruling out IBS than ruling it in. The confident diagnosis of IBS relies on presence of foundational symptoms, recognition of intestinal and extra-intestinal symptoms and psychological stressors that support the IBS diagnosis, detailed medical history and physical examination as well as judicious use of investigations to identify red flag features and exclude organic conditions that mimic IBS. Treatment of IBS involves initial reassurance, dietary, psychological, behavioral interventions, pharmacotherapy based on dominant symptoms, and scheduled patient clinical review, reappraisal, support, and guidance. 2. Checklist to guide your in-clinic review of this patient with IBS symptoms o Rome IV criteria for IBS: Recurrent abdominal pain ≥1 day per week in the last three months related to defecation or associated with change of frequency and/or form (appearance) of stool. o Absence of red flag features (bleeding, anemia, weight loss, nocturnal or progressive symptoms, onset after age 50) o No family history of inflammatory bowel disease, colorectal cancer, or celiac disease
Transcript of Enhanced Primary Care Pathway: · PDF file · 2017-10-20pharmacotherapy based on...
Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME March 2016 - Page 2/6
EnhancedPrimaryCarePathway:IBS
1.FocusedsummaryofIBSrelevanttoprimarycare
Irritablebowelsyndromeisacommonsymptomcomplexcharacterizedbychronicabdominalpainandabnormalbowelfunctioninabsenceoforganiccause.ThesekeyfeaturesofIBScanbewidelyvariableinseverityandmayremitandrecur,oftenbeingaffectedbydietaryfactorsandvariousstressors.Reliefofabdominaldiscomfortafterbowelmovementisadefiningfeature.Boweldysfunctionincludesfrequentbowelmovements,fecalurgencyandevenincontinence,alteredstoolform(hard/lumpyorloose/watery),incompleteevacuation,strainingatstool,andpassageofcopiousmucus.IBSisfrequentlyassociatedwithothergastrointestinalsymptomsincludingbloating,flatulence,nausea,burping,earlysatiety,gastroesophagealreflux,anddyspepsia.Extra-intestinalsymptomsalsofrequentlyoccurinIBSpatientsincludingdysuriaandfrequent,urgenturination,widespreadmusculoskeletalpain,dysmenorrhea,dyspareunia,fatigue,anxiety,anddepression.DiagnosticcriteriaforIBS(e.g.RomeIV)weredevelopedforuniformityofpatientrecruitmentinclinicaltrials.Inclinicalpractice,suchcriteriaonlyprovideaframeworkforassessingpatientswithsuspectedIBS;indeedthesecriteriaalonearefarbetterforrulingoutIBSthanrulingitin.TheconfidentdiagnosisofIBSreliesonpresenceoffoundationalsymptoms,recognitionofintestinalandextra-intestinal symptomsandpsychological stressors that support the IBSdiagnosis,detailedmedicalhistoryandphysicalexaminationaswellasjudicioususeofinvestigationstoidentifyredflagfeaturesandexcludeorganicconditionsthatmimicIBS.Treatment of IBS involves initial reassurance, dietary, psychological, behavioral interventions,pharmacotherapy based on dominant symptoms, and scheduled patient clinical review, reappraisal,support,andguidance.2.Checklisttoguideyourin-clinicreviewofthispatientwithIBSsymptoms
o RomeIVcriteriaforIBS:Recurrentabdominalpain≥1dayperweekinthelastthreemonthsrelatedtodefecationorassociatedwithchangeoffrequencyand/orform(appearance)ofstool.
o Absenceofredflagfeatures(bleeding,anemia,weightloss,nocturnalorprogressivesymptoms,onsetafterage50)
o Nofamilyhistoryofinflammatoryboweldisease,colorectalcancer,orceliacdisease
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EnhancedPrimaryCarePathway:IBS3.Linkstoadditionalresourcesforpatients
CanadianDigestiveHealthFoundationUnderstandingIrritableBowelSyndromehttp://www.cdhf.ca/en/disorders/details/id/12
UpToDate®–BeyondtheBasicsPatientInformationaboutIBS(freelyaccessible)http://www.uptodate.com/contents/irritable-bowel-syndrome-beyond-the-basics?source=search_result&search=ibs&selectedTitle=2%7E1504.Clinicalflowdiagramwithexpandeddetail
This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofIBS,frombothGastroenterologyandPrimaryCareliterature:
DrossmanDAandHaslerWL.RomeIV—FunctionalGIdisorders:Disordersofgut-braininteractionGastroenterology2016;150:1257-61http://www.gastrojournal.org/issue/S0016-5085(15)X0019-9Weinbergetal.AGAInstituteGuidelineonthepharmacologicalmanagementofirritablebowelsyndrome.Gastroenterology2015;147:1146-8http://www.gastrojournal.org/article/S0016-5085(14)01089-0/abstract
KuritzkyL.IndividualizingPharmacologicManagementofIrritableBowelSyndrome.JFamPract.2015;64:S16-21.http://admin.imng.com/fileadmin/qhi/jfp/pdfs/CME_-_Hot_Topics_IBS_article_2.19.16.pdf
Wilkinsetal.DiagnosisandmanagementofIBSinadults.AmericanFamilyPhysician2012;86:419-426http://www.aafp.org/afp/2012/0901/p419.html
Thefollowingisabest-practiceclinicalcarepathwayformanagementofirritablebowelsyndromein theprimarycaremedicalhome,which includesa flowdiagramandexpandedexplanationoftreatmentoptions:
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FlowDiagram:IBSDiagnosisandManagement-ExpandedDetail1. Diagnosisof IBS is basedonRome IV criteria (2016)of abdominalpain related todefecationand
associated with change in stool frequency or form. IBS requires very little initial laboratoryinvestigation – CBC, ferritin, and celiac disease screen according to most guidelines. The fecalimmunochemicaltest(FIT)hasnotbeenvalidatedforinvestigationofIBS-likesymptoms;orderingFITin this circumstance is inappropriate. Anemia or other red flag features increase the likelihood oforganicdiseaseandmandatereferraltoGI.Absenceofredflags,however,doesnotcompletelyexcludethepossibilityoforganicdisease.Variousother intestinalandextraintestinal featuresoftenco-existwithIBSandprovidesupporttothediagnosis.Itisestimatedthatunrecognizedorganicdisorderswillbepresentinabout15%ofpatientswhomeetRomeIVcriteriaanddonothavealarmfeatures.ThemostcommondiseasesthataremislabeledasIBSareceliacdisease,Crohn’sdisease,andmicroscopiccolitis. If C-reactiveprotein is≤0.5mg/dL, theprobabilityof IBD is≤1%. GI cancers are veryunlikelyinpatientsthatmeetusualcriteriaforIBS.AdetailedmedicalhistoryandphysicalexaminationshouldbeperformedatpresentationtoassessforamultitudeofotherconditionsthatmimicIBS.Acarefulreviewofmedicationsshouldbeperformedtoidentify ones that may be causing GI side effects (e.g. PPI, ASA/NSAIDs, laxatives/antacids,iron/calcium/magnesiumsupplements,calciumchannelblockers,antidepressants,opioids,diuretics,herbalproducts).
2. General principles of IBS treatment. All patientswith IBSwill benefit from lifestyle and dietarymodifications,andthismaybeallthatisrequiredinthosewithmildorintermittentsymptomsthatdonotaffectqualityoflife.Keytolong-termeffectivemanagementofIBSistoprovidepatientreassuranceoftheinitialdiagnosisIBSandofferpointsofreassessmentandreappraisaltoestablishatherapeuticrelationship.Connectingpatientswithresourcesfordiet,exercise,stressreduction,andpsychologicalcounselingisimportant.Screenforandtreatanyunderlyingsleepormooddisorder.
3. Specific approachesbasedon IBS subtype. There are three clinical phenotypesof IBS: diarrhea-
predominant(IBS-D),constipation-predominant(IBS-C),andmixedpatternalternatingdiarrheaandconstipation(IBS-M).CategorizingIBSbydominantGIsymptomguidesfocuseduseofafewadditionalinvestigations (particularly in IBS-D), but also guides specific treatment approaches. Use ofpharmaceuticalsinIBSisgenerallyreservedforthosewhohavenotadequatelyrespondedtodietaryandlifestyleinterventions,orinthosewithmoderateorseveresymptomsthatimpairqualityoflife.PainandbloatingisadefiningfeatureofIBSand,insomepatients,thesefeaturesaresevereorfrequentenough to affect quality of life. Antispasmodics may be beneficial in managing or aborting acuteepisodesofpain,andpatientsoftentakereassuranceinhavingtheseon-demandtreatmentsavailable.Forchronic IBSpain, tricyclicantidepressantshaveshownbenefit,andmayhaveaddedbenefits inthosepatientswithmoodorsleepissues.In absence of alarm features, what would prompt referral for GI consultation and possiblecolonoscopy? Colonoscopy may be helpful in patients with diarrhea predominance who havepersistent symptomsor limitedbenefit fromusual treatments.This ismainly to assess forCrohn’sdiseaseandmicroscopiccolitis.Inpatientswithconstipationpredominanceoralternatingdiarrheaandconstipation,colonoscopyisveryunlikelytoyieldrelevantfindings.
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PrinciplesandSpecificsofIBSManagementbySubtype
AllsubtypesofIBS
Exercise Moderatetovigorousexercisefor20-60minutes3-5xperweek
SolubleFibreUseinIBSremainscontroversial,asmaybebeneficialinsomebutdetrimentalinothers.Reasonabletotrypsylliumhuskone-halftoonetablespoondaily.Insolublefibrelikebranisnotbeneficial.
Probiotics Bifidobacteriuminfantis(Align®)1capsule/d($40/mo.)Lactobacillusplantarum229v(TuZen®)1-2capsules/d($40-80/mo.)
Antispasmodics
Peppermintoil(0.2to0.275mLcaps,entericcoated)2capsulesBID($20-25/mo.)HyoscineButylbromide(Buscopan®)10mgTID-QID($25-40/mo.)Dicyclominehydrochloride(Bentylol®)20mgTID-QID($25-40/mo.)PinaveriumBromide(Dicetel®)50-100mgTID($50-75/mo.)Trimebutine(Modulon®)100-200mgTID($40-80/mo.)Allprescribedantispasmodicmedicationsshouldbefullydiscussedwiththepatientintermsofspecificrisksandsideeffectsandappropriatenessofuseincontextoftheirfullmedicalhistory
Antidepressants
Nortriptylineoramitriptyline10-25mgqhs,doseescalateby10-25mg/wkMayrequire25-150mg/d($20-60/mo.);usuallytakes2-3mos.forpeakeffectParticularlyusefulinpatientswithdiarrheaandpainpredominanceorsleepissues/anxiety/depressionUsewithcautioninpatientsatriskofprolongedQT;notesomnolenceandanticholinergicsideeffectsLatestIBStechnicalreviewdoesnotendorseuseofSSRIs
ComplementaryTherapies
PsychologicaltreatmentsMindfulness-basedstressreduction(www.thebreathproject.org)HypnotherapyAccupunctureYoga(www.yogacalgary.ca)
HealthyLiving/SelfManagement AlbertaHealthyLivingProgram(ahs.ca/info/cdmcalgaryzone.asp)
Diarrhea-PredominantIBS
Antidiarrheals
Loperamide(Imodium®)2-4mgBID($25-50/mo.OTC)Cholestyraminepowder(Olestyr®$0.40/g),colestipol(Colestid®$0.25/g)tabletsorpowderorcolesevelam(Lodalis®$1.80/g)tabletsorpowder,1-4gpoOD-TIDEspeciallyusefulpost-cholecystectomy.Adviseregardingtimingwithothermedicationstoavoidinteraction;iflongtermuse,riskoffatsolublevitamindeficiencies
FODMAPs CanadianDigestiveHealthFoundationcdhf.ca/bank/document_en/32-fodmaps.pdf
GlutenAvoidance Nonceliacglutensensitivity
Antibiotics Rifaximin(Zaxine®)550mg3x/dailyfor2weekswhichcosts~$325!
Constipation-PredominantIBS
PEG-basedLaxatives Mira-Lax®orLax-a-Day®17-34g/d($25-50/mo.)
Prokinetics Linaclotide(Constella®)290µg/d30minutesbeforebreakfast($160/mo.)Prucalopride(Resotran®)2mg/d,4weektrial($120/mo.)
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