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PHARM 345 - 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
Non-Pharm Management of IBS - Diet
- More fibre - Avoid FODMAP foods - Avoid food triggers (dairy, wheat, sorbitol sweeteners) - Avoid foods that increase flatulence (gum, soda, drinking with straw)
26
Non-Pharm Management of IBS - Prebiotics
Food that remains undigested that can then stimulate colonic bacteria - Reduces excess gas and bloating
27
Non-Pharm Management of IBS - Probiotics
Live microorganisms that affect the composition and function of the gut microbiota - Reduces inflammation and reduces nociception
28
Non-Pharm Management of IBS - Patient educations
- Validate patient, their symptoms are real and not just in their mind - Educate patients to avoid symptom triggers - Determine triggers through daily symptom diaries
29
Water soluble fibre - Indications
First line therapy for IBS-C
30
Water soluble fibre - Dose
Start at 4-8 g/day and slowly titrate up
31
Water soluble fibre - Considerations
- Insoluble fibres can cause bloating and worsen symptoms in some patients - May have to add bulk forming laxative (Psyllium, methycellulose)
32
Osmotic Laxatives - Indications
Second line therapy for IBS-C - Used when fibre supplementation is not enough
33
Osmotic Laxatives - Options
First line: PEG Second line: Lactulose (Increases gas though) For severe constipation or PRN to provide quick relief - Magnesium citrate / Magnesium hydroxide - Glycerin suppositories
34
Stimulant Laxatives - Indications
Used in IBS-C - Can cause more cramping in some patients with IBS
35
Guanylate Cyclase C Agonists - MOA
Activates Guanylate Cyclase C receptors - Increases intestinal fluid secretions and motility
36
Guanylate Cyclase C Agonists - Examples
- Linaclotide - Plecanatide
37
Guanylate Cyclase C Agonists - Indication
Used in moderate to severe IBS-C - Considered for patients who have not responded to other IBS-C agents
38
Guanylate Cyclase C Agonists - Consideratiosn
- Contraindicated in children younger than 6 years of age (Risk of dehydration)
39
Guanylate Cyclase C Agonists - Efficacy
- 1 week for improvement of bowel movement frequency - 4 weeks for relief of abdominal cramping
40
Guanylate Cyclase C Agonists - Adverse Effects
Common: - Diarrhea - Abdominal pain/cramping - Flatulence - Bloating Rare but Serious - Dehydration
41
5-HT4 Agonist - Examples
Prucalopride
42
5-HT4 Agonist - MOA
5HT4 agonist, resulting prokinetic effect
43
5-HT4 Agonist - Indication
Consider for severe constipation in women with IBS-C who have not responded to other agents
44
5-HT4 Agonist - Efficacy
Increases motility and transit throughout GIT - Improve Quality of Life
45
5-HT4 Agonist - Adverse Effects
Common: - Diarrhea - Nausea - GI pain - Headache Rare but Serious - Arrhythmia
46
Derivative of PGE1 - Example
Lubiprostone
47
Derivative of PGE1 - MOA
Activates intestinal chloride channel - Enhances intestinal fluid secretion - Increases GI motility
48
Derivative of PGE1 - Indication
Used in IBS-C in females - Increases spontaneous bowel movements - Reduces abdominal pain and bloating
49
Derivative of PGE1 - Dose
8 mcg twice daily with food
50
Derivative of PGE1 - Adverse Effect
- Diarrhea - Bloating - Abdominal Pain - Nausea
51
Management of IBS-C
First Line: Water Soluble FIbre Second Line: Osmotic Laxative (PEG, Lactulose)
52
Management of IBS-D
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
IBS and Bile Acid Malabsorption
25% of patients with IBS-D have bile acid malabsorption - From rapid GI transport
54
Rifaximin - MOA
Poorly absorbed broad spectrum antibiotic - Alters the gut microflora
55
Rifaximin - Indication
More effective in IBS-D - Especially if bacterial overgrowth is causing excessive bloating
56
Rifaximin - Efficacy
- Improvement in IBS symptoms - Improvement in bloating - Decrease in pain
57
Rifaximin - Adverse Effects
Minimal side effects
58
Eluxadoline - MOA
mu-opioid receptor agonist, acts locally in gut - Improves stool consistency/frequency - Does not help as much for abdominal pain and bloating
59
Eluxadoline - Indication
Consider for IBS-D patients who have not responded to other anti-diarrheals
60
Eluxadoline - Adverse Effects
- Nausea - Constipation Rare - Pancreatitis (Mainly in patients with no gallbladder)
61
Eluxadoline - Considerations
Avoid use in patients with: - Alcohol misuse - Patients with pancreatitis - Liver disease - Biliary duct obstruction - History of cholecystectomy
62
Management of IBS-M
First Line: Soluble Fibre Then treat according to bowel symptoms being experienced - Discontinue laxative if diarrhea occurs - Discontinue antidiarrheal if constipation occurs
63
Antispasmodic Agents
- Anticholinergic - GI Specific Calcium Channel Antagonists - Antispasmodic Opioid Agonists Limit to short term management of pain symptoms only
64
Pain in IBS: Anticholinergic - Examples
- Dicyclomine - Hyoscine
65
Pain in IBS: Anticholinergic - Adverse Effects
- Dry mouth - Constipation - Urinary Retention - Blurred Vision
66
Pain in IBS: Anticholinergic - Consideration
- Limit use - Take before meals - Works quickly
67
Pain in IBS: GI Specific Calcium Channel Antagonist - Examples
Pinaverium
68
Pain in IBS: GI Specific Calcium Channel Antagonist - Adverse Effeccts
- Epigastric irritation - Fullness - Constipation
69
Pain in IBS: GI Specific Calcium Channel Antagonist - MOA
Decreases muscle contraction - Provides local relief in GI tract
70
Pain in IBS: GI Specific Calcium Channel Antagonist - Considerations
- Take with full glass of water and food - Do not lie down
71
Pain in IBS: Antispasmodic Opioid Agonist - Examples
Trimebutine
72
Pain in IBS: Antispasmodic Opioid Agonist - MOA
Reduces pain signals and reduces spasms
73
Pain in IBS: Antispasmodic Opioid Agonist - Adverse Effects
- Dry mouth - Drowsiness - Dizziness - Nausea - Diarrhea - Constipation
74
Pain in IBS: Antispasmodic Opioid Agonist - Considerations
Anti 5-HT activity and moderate opiate receptor affinity
75
Pain in IBS: Tricyclic Antidepressants - MOA
Anticholinergic and analgesic effects
76
Pain in IBS: Tricyclic Antidepressants - Indication
For patients with intractable pain
77
Pain in IBS: Tricyclic Antidepressants - Efficacy
- Decrease in abdominal pain - Decrease in diarrhea - Decrease in stool frequency
78
Pain in IBS: Tricyclic Antidepressants - Adverse Effects
Anticholinergic - Constipation - Sedation - Dry mouth - Blurry vision - Orthostatic hypotension - Urinary retention
79
Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants - MOA
Prevents 5-HT reuptake in presynaptic neurons - Minimal effects on norepinephrine or dopamine - GI motility is linked to 5-HT
80
Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants - Indication
More effective in IBS-C - Use in patients with comorbid depression or anxiety
81
Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants - Efficacy
Increases GI motility, works on brain-gut axis
82
Pain in IBS: Selective Serotonin Reuptake Inhibitors (SSRI) Antidepressants - Adverse Effects
- Nausea - Diarrhea - Insomnia or Sedation - Dizziness - Nervousness - Sexual dysfunction
83
Pain in IBS: NHP - Example
Peppermint - Dried extract - Tea - Lozenge - Dried leaf
84
Pain in IBS: NHP - MOA
Antispasmodic effect on smooth muscles
85
Pain in IBS: NHP - Indication
- Reduces abdominal pain - Reduces distension - Reduces flatulence
86
Pain in IBS: NHP - Efficacy
More data with IBS-D, however, may be effective in IBS-C
87
Pain in IBS: NHP - Adverse Effects
- Heartburn (Lowers LES pressure) - Mouth ulcerations (reduce by using enteric coating)
88
Treatment Summary - Constipation
- Water Soluble Fibre - Osmotic Laxative - GC-C agonists - 5HT4 Agonist - Lubiprostone
89
Treatment Summary - Diarrhea
- Soluble Fibre - Loperamide, Diphenoxylate/Atropine - Eluxadoline - Cholestyramine - Rifaximin
90
Treatment Summary - Pain
- 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 345 - Other (36 decks)

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