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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.)