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PHARM 346 - Other > Irritable Bowel Syndrome > Flashcards

Irritable Bowel Syndrome Flashcards

1
Q

Risk Factors of IBS

A
  • Genetics
  • Prior GI infection
  • Mechanical irritation to GIT nerves
  • Stress
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2
Q

Which groups is IBS more common in

A

Females
Younger than 40

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3
Q

Comorbidities of IBS

A
  • Psychological / Affective disorders (Panic attacks, anxiety, depression)
  • Fibromyalgia (60% of pts with this have IBS)
  • IBD or Colitis (2-3 times more likely to have IBS)
  • Celiac disease (5x higher with IBS)
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4
Q

What causes IBS (Brain-Gut Axis Disorder)

A

Sensorimotor disturbances in bowels
- Visceral hypersensitivity
- Lowered pain threshold
- Motor dysfunction of intestines

Peripheral Enteric Nervous System and Central Nervous System

Downregulation of 5-HT receptors in GI tract

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5
Q

Function of Serotonin Receptors in GI

A

5-HT3 regulates GIT motility and transmission of pain signals

5HT4 increases GIT contractions

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6
Q

What causes IBS (Other Theory)

A

Small intestine bacterial overgrowth (SIBO)
- Mostly seen in IBS
- Unclear if its an actual cause of just coincidence

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7
Q

IBS
- Symptom (Pain)

A

Lower abdominal pain (2/3 of patients)
- Crampy achy
- Relieved with defecation
- Worsened by meals

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8
Q

IBS
- Symptom (Flatulence)

A
  • Bloating
  • Abdominal distension
  • Gas
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9
Q

IBS
- Symptom (Stools)

A

Changes in bowel habits
- Diarrhea (>3 stools/day)
- Constipation (<3 stools/week with straining)
- Or alternating between diarrhea and constipation

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10
Q

IBS
- Symptoms (Other)

A
  • Dyspepsia
  • Urinary symptoms
  • Fatigue
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11
Q

IBS
- Red Flags

A
  • Nocturnal Symptoms
  • First Incidence >50 years
  • Unexplained weight loss
  • Blood in stools
  • Fever
  • Abdominal mass
  • Moderate to severe abdominal pain
  • Progressive worsening of symptoms
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12
Q

Triggers of IBS

A
  • Psychological (Stress, anger)
  • Diet (Alcohol, Fatty foods, caffeine, FODMAPS)
  • Hormone fluctuations (Common in Dysmenorrhea)
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13
Q

FODMAPs

A

Fermentable
Oligosaccharides
Disaccharide (Milk)
Monosaccharide (High fructose and glucose)
And
Polyols (Sugar alcohols)

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14
Q

Rome IV Criteria

A

Recurrent abdominal pain once per week during the previous 3 months related to 2 of the following:
- Related to defecation (Relief with defecation)
- Associated with a change in stool frequency
- Change in stool appearance

Symptoms onset should be at least 6 months before diagnosis

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15
Q

IBS Diagnosis

A

Abdominal pain associated with a change in bowel habits for at least 3 months

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16
Q

How to diagnosis IBS over IBD

A

Perform a Fecal lactoferrin or CRP test

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17
Q

What diagnosis tests should be avoided

A
  • Colonoscopy
  • Fecal occult blood
  • Ova/parasite stool test
  • Testing for food allergies
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18
Q

IBS-D

A

Diarrhea predominant IBS
- More than 25% loose stools
- Less than 25% hard stools

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19
Q

IBS-C

A

Constipation predominant IBS
- More than 25% hard stools
- Less than 25% loose stools

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20
Q

IBS-M

A

Mixed predominant IBS
- More than 25% hard stools
- More than 25% loose stools

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21
Q

IBS-U

A

Unclassified predominant IBS
- Variable hard stools
- Variable loose stools

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22
Q

Non-Pharm Management of IBS

A
  • Soluble fibre for everyone
  • Diet
  • Prebiotics
  • Probiotics
  • Lifestyle interventions
  • Psychological therapy
  • Patient education
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23
Q

Non-Pharm Management of IBS
- Psychological

A

Aims to alleviate anxiety and distress over symptoms
- Not clear if it helps frequency of bowel symptoms

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24
Q

Non-Pharm Management of IBS
- Lifestyle

A
  • Increase physical activity
  • Decrease binge drinking of alcohol
  • No evidence that caffeine worsens IBS symptoms despite it affecting colon motor activity
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25
Q

Non-Pharm Management of IBS
- Diet

A
  • More fibre
  • Avoid FODMAP foods
  • Avoid food triggers (dairy, wheat, sorbitol sweeteners)
  • Avoid foods that increase flatulence (gum, soda, drinking with straw)
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26
Q

Non-Pharm Management of IBS
- Prebiotics

A

Food that remains undigested that can then stimulate colonic bacteria
- Reduces excess gas and bloating

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27
Q

Non-Pharm Management of IBS
- Probiotics

A

Live microorganisms that affect the composition and function of the gut microbiota
- Reduces inflammation and reduces nociception

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28
Q

Non-Pharm Management of IBS
- Patient educations

A
  • Validate patient, their symptoms are real and not just in their mind
  • Educate patients to avoid symptom triggers
  • Determine triggers through daily symptom diaries
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29
Q

Water soluble fibre
- Indications

A

First line therapy for IBS-C

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30
Q

Water soluble fibre
- Dose

A

Start at 4-8 g/day and slowly titrate up

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31
Q

Water soluble fibre
- Considerations

A
  • Insoluble fibres can cause bloating and worsen symptoms in some patients
  • May have to add bulk forming laxative (Psyllium, methycellulose)
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32
Q

Osmotic Laxatives
- Indications

A

Second line therapy for IBS-C
- Used when fibre supplementation is not enough

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33
Q

Osmotic Laxatives
- Options

A

First line: PEG
Second line: Lactulose (Increases gas though)

For severe constipation or PRN to provide quick relief
- Magnesium citrate / Magnesium hydroxide
- Glycerin suppositories

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34
Q

Stimulant Laxatives
- Indications

A

Used in IBS-C
- Can cause more cramping in some patients with IBS

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35
Q

Guanylate Cyclase C Agonists
- MOA

A

Activates Guanylate Cyclase C receptors
- Increases intestinal fluid secretions and motility

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36
Q

Guanylate Cyclase C Agonists
- Examples

A
  • Linaclotide
  • Plecanatide
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37
Q

Guanylate Cyclase C Agonists
- Indication

A

Used in moderate to severe IBS-C
- Considered for patients who have not responded to other IBS-C agents

38
Q

Guanylate Cyclase C Agonists
- Consideratiosn

A
  • Contraindicated in children younger than 6 years of age (Risk of dehydration)
39
Q

Guanylate Cyclase C Agonists
- Efficacy

A
  • 1 week for improvement of bowel movement frequency
  • 4 weeks for relief of abdominal cramping
40
Q

Guanylate Cyclase C Agonists
- Adverse Effects

A

Common:
- Diarrhea
- Abdominal pain/cramping
- Flatulence
- Bloating

Rare but Serious
- Dehydration

41
Q

5-HT4 Agonist
- Examples

A

Prucalopride

42
Q

5-HT4 Agonist
- MOA

A

5HT4 agonist, resulting prokinetic effect

43
Q

5-HT4 Agonist
- Indication

A

Consider for severe constipation in women with IBS-C who have not responded to other agents

44
Q

5-HT4 Agonist
- Efficacy

A

Increases motility and transit throughout GIT
- Improve Quality of Life

45
Q

5-HT4 Agonist
- Adverse Effects

A

Common:
- Diarrhea
- Nausea
- GI pain
- Headache

Rare but Serious
- Arrhythmia

46
Q

Derivative of PGE1
- Example

A

Lubiprostone

47
Q

Derivative of PGE1
- MOA

A

Activates intestinal chloride channel
- Enhances intestinal fluid secretion
- Increases GI motility

48
Q

Derivative of PGE1
- Indication

A

Used in IBS-C in females
- Increases spontaneous bowel movements
- Reduces abdominal pain and bloating

49
Q

Derivative of PGE1
- Dose

A

8 mcg twice daily with food

50
Q

Derivative of PGE1
- Adverse Effect

A
  • Diarrhea
  • Bloating
  • Abdominal Pain
  • Nausea
51
Q

Management of IBS-C

A

First Line: Water Soluble FIbre

Second Line: Osmotic Laxative (PEG, Lactulose)

52
Q

Management of IBS-D

A

First Line: Dietary management
- Soluble fibre, acts as a bulking agent to improve symptoms

Second Line: Antidiarrheals
- Loperamide, used daily
- Diphenoxylate-atropine, used PRN

If bile acid malabsorption: Bile-Acid Binding Resins
- Cholestyramine
- Colesevelam

53
Q

IBS and Bile Acid Malabsorption

A

25% of patients with IBS-D have bile acid malabsorption
- From rapid GI transport

54
Q

Rifaximin
- MOA

A

Poorly absorbed broad spectrum antibiotic
- Alters the gut microflora

55
Q

Rifaximin
- Indication

A

More effective in IBS-D
- Especially if bacterial overgrowth is causing excessive bloating

56
Q

Rifaximin
- Efficacy

A
  • Improvement in IBS symptoms
  • Improvement in bloating
  • Decrease in pain
57
Q

Rifaximin
- Adverse Effects

A

Minimal side effects

58
Q

Eluxadoline
- MOA

A

mu-opioid receptor agonist, acts locally in gut
- Improves stool consistency/frequency
- Does not help as much for abdominal pain and bloating

59
Q

Eluxadoline
- Indication

A

Consider for IBS-D patients who have not responded to other anti-diarrheals

60
Q

Eluxadoline
- Adverse Effects

A
  • Nausea
  • Constipation

Rare
- Pancreatitis (Mainly in patients with no gallbladder)

61
Q

Eluxadoline
- Considerations

A

Avoid use in patients with:
- Alcohol misuse
- Patients with pancreatitis
- Liver disease
- Biliary duct obstruction
- History of cholecystectomy

62
Q

Management of IBS-M

A

First Line: Soluble Fibre

Then treat according to bowel symptoms being experienced
- Discontinue laxative if diarrhea occurs
- Discontinue antidiarrheal if constipation occurs

63
Q

Antispasmodic Agents

A
  • Anticholinergic
  • GI Specific Calcium Channel Antagonists
  • Antispasmodic Opioid Agonists

Limit to short term management of pain symptoms only

64
Q

Pain in IBS: Anticholinergic
- Examples

A
  • Dicyclomine
  • Hyoscine
65
Q

Pain in IBS: Anticholinergic
- Adverse Effects

A
  • Dry mouth
  • Constipation
  • Urinary Retention
  • Blurred Vision
66
Q

Pain in IBS: Anticholinergic
- Consideration

A
  • Limit use
  • Take before meals
  • Works quickly
67
Q

Pain in IBS: GI Specific Calcium Channel Antagonist
- Examples

A

Pinaverium

68
Q

Pain in IBS: GI Specific Calcium Channel Antagonist
- Adverse Effeccts

A
  • Epigastric irritation
  • Fullness
  • Constipation
69
Q

Pain in IBS: GI Specific Calcium Channel Antagonist
- MOA

A

Decreases muscle contraction
- Provides local relief in GI tract

70
Q

Pain in IBS: GI Specific Calcium Channel Antagonist
- Considerations

A
  • Take with full glass of water and food
  • Do not lie down
71
Q

Pain in IBS: Antispasmodic Opioid Agonist
- Examples

A

Trimebutine

72
Q

Pain in IBS: Antispasmodic Opioid Agonist
- MOA

A

Reduces pain signals and reduces spasms

73
Q

Pain in IBS: Antispasmodic Opioid Agonist
- Adverse Effects

A
  • Dry mouth
  • Drowsiness
  • Dizziness
  • Nausea
  • Diarrhea
  • Constipation
74
Q

Pain in IBS: Antispasmodic Opioid Agonist
- Considerations

A

Anti 5-HT activity and moderate opiate receptor affinity

75
Q

Pain in IBS: Tricyclic Antidepressants
- MOA

A

Anticholinergic and analgesic effects

76
Q

Pain in IBS: Tricyclic Antidepressants
- Indication

A

For patients with intractable pain

77
Q

Pain in IBS: Tricyclic Antidepressants
- Efficacy

A
  • Decrease in abdominal pain
  • Decrease in diarrhea
  • Decrease in stool frequency
78
Q

Pain in IBS: Tricyclic Antidepressants
- Adverse Effects

A

Anticholinergic
- Constipation
- Sedation
- Dry mouth
- Blurry vision
- Orthostatic hypotension
- Urinary retention

79
Q

Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants
- MOA

A

Prevents 5-HT reuptake in presynaptic neurons
- Minimal effects on norepinephrine or dopamine
- GI motility is linked to 5-HT

80
Q

Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants
- Indication

A

More effective in IBS-C
- Use in patients with comorbid depression or anxiety

81
Q

Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants
- Efficacy

A

Increases GI motility, works on brain-gut axis

82
Q

Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants
- Adverse Effects

A
  • Nausea
  • Diarrhea
  • Insomnia or Sedation
  • Dizziness
  • Nervousness
  • Sexual dysfunction
83
Q

Pain in IBS: NHP
- Example

A

Peppermint
- Dried extract
- Tea
- Lozenge
- Dried leaf

84
Q

Pain in IBS: NHP
- MOA

A

Antispasmodic effect on smooth muscles

85
Q

Pain in IBS: NHP
- Indication

A
  • Reduces abdominal pain
  • Reduces distension
  • Reduces flatulence
86
Q

Pain in IBS: NHP
- Efficacy

A

More data with IBS-D, however, may be effective in IBS-C

87
Q

Pain in IBS: NHP
- Adverse Effects

A
  • Heartburn (Lowers LES pressure)
  • Mouth ulcerations (reduce by using enteric coating)
88
Q

Treatment Summary
- Constipation

A
  • Water Soluble Fibre
  • Osmotic Laxative
  • GC-C agonists
  • 5HT4 Agonist
  • Lubiprostone
89
Q

Treatment Summary
- Diarrhea

A
  • Soluble Fibre
  • Loperamide, Diphenoxylate/Atropine
  • Eluxadoline
  • Cholestyramine
  • Rifaximin
90
Q

Treatment Summary
- Pain

A
  • Antispasmodics (IBS-C,D,M)
  • SSRI (IBS-C,M)
  • GC-c Agonists (IBS-C)
  • TCA Antidepressants (IBS-D,M)
  • Lubiprostone (IBS-D,M)
  • Eluxadoline (IBS-D)
  • Rifaximin (IBS-D)

PHARM 346 - Other (17 decks)

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