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

*

IBS-C

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.