67: IBS Flashcards
Syndrome
-number of symptoms occuring together and characterizing a specific disease
IBS
-ab pain
-cramping
-changes in bowel function
-most common GI disorder
-chronic
IBS epidemiology
-5-15%
-mostly mild
-no inflammation, changes in tissue or inc risk of colorectal cancer
-more women under 50
-low socioeconomic status
IBS patho
-ab pain w abnormal bowel movements
-can be constipation predominant or diarrhea predominant OR alternate :)
-though to be due to somatovisceral and motor dysfunction of intestine
-pain independent of motility and psych disturbance
-majority of serotonin receptors in enteric nervous system
IBS non GI symptoms
-urinary
-lower back pain
-fatigue
-dyspareunia (painful sex)
common-co morbities of IBS
-fibromyalgia
-functional dyspepsia
-chronic fatigue syndrome
IBS diagnosis
-no biomarkers of disease know
-celiac indicated
-lactose intolerance suspicion
-colonoscopy no needed if no alarm features
IBS diagnostic critera
-recurrent ab pain at lead once a week in previous 3 months
-inc pain related to pooping
-change in freq of stool
-change in appearance of stool
IBS alarming features
-rectal bleeding
-weight loss
-iron deficient anemia
-nocturnal symptoms
-fam hx of colorectal cancer, IBD, or celiac
-onset before age 50
Dietary tx of IBS
-AVOID foods that make it worse
-low FODMAP diet
-fermentable ssugars
-fiber water exercise
Non pharma tx of IBS
-physical activity
-cognitive behavioral therapy
-gut telling brain to contract so working with that
IBS-C onstapation predominant tx
- inc fiber + fluid
- add bulk lax
- consider anti-spasmodic/anticholinerfic agent for pain/cramping
- consider lubipro$tone or linaclotide $ for constipation and ab pain
- psychotherapeutic behvior modification, consider antidepressants
- consider serotonin-4 agonist as last line
bulk lax (step 2) for IBS-C
-soluble fiber psyllium
-PEG
psyllium
-20-30g fiber qd
-1tbsp wf start qd inc to TID
-can worsen IBS symptoms
PEG for IBS-C
-osmotic lax
-17g titrate to effect and tolerability
Anti-spasmodic therapy for IBS-C
-hyoscyamine
-dicyclomine
-anticholinergic, blocks AcH on PSNS
-improves ab pain
-use caution in elderly
-avoid in glaucoma
-avoid if constipation
-most used
Hyoscyamine (levsin)
-anti-spasmodic for IBS-C
-0.125-0.25mg q4h prn, max 1.5mg
-dizziness, somnolence, blurred vision
Dicyclomine (Bentyl)
-20mg QID for 7 days may inc to 40
-evaluate 2 weeks
-dry mouth, dizziness, dec appetite, blurred vision
IBS-C antidepressants
-SSRIs
-Citalopram 10mg
-Escitalopram 10mg
-Fluoxetine 20mg
-Fluvoxamine 50mg
-Paroxetine 20mg
-Sertraline 25mg
-reduce sensitivity
-N/V, sex probs, sedation, insomnia
Pro-secretory agents for IBS-C tx
-Lupirostone 8mcg BID
-Linaclotide 290mcg qd
Lubiprostone
-pro-secretory for IBS-C tx
-chloride channel activator, inc intestinal secretions
-8mcg BID
-N, HA, diarrhea
-AVOID in preg
-AVOID in intestinal block
-take wf and water
-woment over 18
-24mcg for CIO
Linaclotide
-prosecretory agent for IBS-C
-inc cGMP
-inc secretion of chloride and bicarbonate in intestine
=inc fluid and dec transit time
-290mcg qd
-diarrhea worse w high fat meals
-DO NOT USE IN KIDS UNDER 17 DEHYDRATION RISK
-30 min before first meal
-CIC at 145mcg
-keep in og container she dont like to get wet
5-HT4 agonist for IBS-C
-Tegaserod
Tegaserod
-6mg BID before meals for 4-6 week
-can continue if response
-stimulates peristalsis and secretions
-modulates sensitivity
-HA, ab pain, dizziness, diarrhea, CV events
-only available thru FDA under emergency protocol
IBS-D tx non pharma
-manage stress
-cut out lactose and caffeine
-avoid foods that inc symptoms
Tx of IBS-D iarrhea
- Diet
- add loperamide or dicyclomine (anti-spasmodic)
2a. Replace w eluxadoline if pain persists
2b. consider rifaximin - add serotonin-3 ANTAgonist
- behavior mod, consider antidepressants
Loperamide
-4mg start, 2mg after each loose stool max 16mg/day
-inhibits peristalsis and GI secretions
-mods sensitivity
-constipation BBB concern
-dependence
-reduces diarrhea but no effect on ab pain
Diphenoxylate-atropine
-5mg TID-QID PRN
-max 20mg/day
-antidiarrheal
Anti-diarrheals
-loperamide
-diphenoxylate-atropine
Opioid receptor agonist for IBS-D
-Eluxadoline
Eluxadoline
-100mg BID (75 is nogallbladder)
-mu-opioid receptor AGONIST
-reduce ab pain and diarrhea
-dizziness, euphoria, fatigue, constipation, pancreatitis
-AVOID in pt w hx of pancreatitis, alcholism, child class C
-CIV due to abuse potential
-CYP metabolism
5-HT3 ANTAgonists for IBS-D
-Alosetron 0.5mg BID
Alosteron
-5HT3 ANTAgonist for IBS-D
-dec sensitivity and motility
-0.5mg BID max 2mg
-constipation, ischemic colitis black box
-REMs
-CYP metabolism
-AVOID in child class C
Additional agents to treat IBS-D
-Rifaximin
-Peppermint oil
-Probiotics
Rifaximin
-poorly absorbed non-systemic
-targets gut
-550mg TID 14 days
-may repeat up to two times
-dizziness, fatigue, edema
Peppermint oil
-for IBS-D
-dec upset tummy, bloating, gas, urgency
-1-2 caps PRN upto TID
-take 30 min AC or PC
Probiotics for IBS-D
-motility, sensitivity, inflammation, barrier integrity, microflora
IBS-D antidepressants
-Nortriptyline 10mg
-Amitriptyline 25mg
-Trimipramine 25mg
-Desipramine 25mg
-reduce sensitivity and stress
-constipation, dry mouth, drowsiness, weight gain
-most beneficial in pt w IBS-D
-QT prolongation
