Diarrhea/IBS

Question 1

Bismuth subsalicylate MOA/indications

Answer 1

MOA: Exhibits both anti-secretory, anti-inflammatory, & antimicrobial action

Indications

• Symptomatic tx of mild diarrhea
• Prevention & control of Thao’s Traveler’s diarrhea**

Question 2

Bismuth subsalicylate ADRs

Answer 2

• Darkening of tongue (brush teeth after) & stool*
• Constipation**
• Effects of ASA

Question 3

Loperamide indications

Answer 3

MC: Acute nonspecific noninflammatory diarrhea

-Also used for the tx of IBS-D

Question 4

Abuse of loperamide is common. What is this linked with?

Answer 4

-serious arrhythmia and death

“Poor mans methadone”

-has opioid like effects at high doses

Question 5

Loperamide Contraindications/ADRs

Answer 5

CI
-Acute IBD or inflammatory infectious diarrhea

ADRs

• Constipation
• Death if overdose

Question 6

Diphenoxylate & Atropine MOA

Answer 6

MOA: Inhibits excessive GI motility & GI propulsion
-Atropine to discourage abuse

-Same indications, CI, and ADRs as loperamide

Question 7

What are the 4 classifications of IBS

Answer 7

• IBS w/ constipation (IBS-C)
• IBS with diarrhea (IBS-D)
• IBS mixed (IBS-M)
• IBS unclassified (IBS-U)

Question 8

What is the goal of the treatment of IBS?

Answer 8

-Since the exact cause of IBS is unknown, the goal is to manage the symptoms**

Question 9

What is “KEY” in the management of IBS

Answer 9

• Stress reduction***

- Exercise including yoga may improve the symptoms as well

Question 10

What is an acronym for the dietary changes used in IBS?

Answer 10

Low FODMAP diet
-Fermentable Oligosaccharides, Disaccharides, Monosaccharides, & Polyols

-Also reasonable to avoid gluten

Question 11

What dietary supplementation may be helpful?

Answer 11

-Soluble fiber may be helpful for IBS-C and IBS-D, limited effect on symptoms such as pain

Question 12

Stepwise approach to IBS

Answer 12

1. Stress reduction
2. Exercise
3. Dietary education (Low FODMAP)
4. Dietary/supplementary fiber
5. Laxatives: IBS-C patients who don’t respond to fiber
6. Antidiarrheal: IBS-D can use them as needed
7. Antispasmodics

Question 13

Antispasmodics, MOA

Answer 13

• Hyoscyamine
• Dicyclomine

MOA: Induce intestinal smooth muscle relaxation through myorelaxant effects or anticholinergic mechanisms

Question 14

Antispasmodics indications/ADRs

Answer 14

-Best used for PRN acute attacks of abdominal pain with postprandial symptoms

ADRs
-High dose may lead to anticholinergic ADRs

Question 15

IBS “Other Options” that have been approved for IBS-C

Answer 15

• Lubiprostone
• Linaclotide & plecanatide

**See constipation flashies

Question 16

Tegaserod MOA

Answer 16

-Serotonin plays a major role in regulation of GI motility, secretion, & sensation
MOA: Stimulation of 5-HT causes increased secretions and intestinal transit

Question 17

Tenapanor MOA, indications, CI/ADRs

Answer 17

MOA: Inhibits sodium/hydrogen exchange, resulting in increased secretions and accelerations of intestinal transit time

-Indications: IBS-C

• CI in obstruction pts
• Diarrhea is a common ADR

Question 18

Eluxadoline MOA

Answer 18

• Mu opioid receptor agonist & delta opioid receptor antagonist
• Tx of IBS-D

ADRs: Nausea, constipation, abd pain

Question 19

What do patients on Eluxadoline have an increased risk for?

Answer 19

-Pancreatitis

Question 20

Alosetron

Answer 20

• Serotonin (5-HT3) antagonist

- Highly restricted, last resort for women with severe IBS-D

Question 21

Rifaximin

Answer 21

-Approved for the treatment of IBS-D

MOA: thought to alter the microbiota to reduce inflammation

Question 22

Antidepressants for IBS

Answer 22

-Used in moderate-severe IBS pts to releive pain, alter GI transit, and treat psych comorbids

• TCAs: May cause constipation (helpful in IBS-D)
• SSRIs: May cause diarrhea (Helpful in IBS-C)

Question 23

Probiotics for IBS

Answer 23

-Causes change in intestinal flora and may improve pain, bloating, and flatulence

Question 24

Peppermint oil MOA

Answer 24

• Anti-spasmodic properties due to blockade of calcium channels
• OTC

-ADR: Heartburn

Question 25

What is a non-pharm tx option of IBS?

Answer 25

-Psychotherapy