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PHARM 345 GI/NUTRITION > Lecture 6 IBS > Flashcards

Lecture 6 IBS Flashcards

1
Q

What is IBS

A

Functional gastrointestinal disorder

Characterized by chronic and or recurrent pain or dscomfort and altered bowel habits

Most common GI disorder seen by primary care physicians

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2
Q

T/F IBS is 2-3 times more common in females than males

A

True

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3
Q

Potential risk factors of IBS

A

Genetic predisposition

GI Infection with subsequent inflammation may play role

Mechanical irritation to GIT nerves

Stressful life events

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4
Q

Common comorbidities with IBS

A

Close associated with psychological affective disorders

Overlap with fibromyalgia

Presence of IBD or Colitis

Presence of celiac disease

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5
Q

Pathophysiology: Brain- Gut axis disorder

A

Sensorimotor disturbances of small/large bowel

May involve both the peripheral enteric nervous system and the central nervous system

May be related to downregulation of serotonin receptors in the GI tract

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6
Q

Symptoms of IBS

A

Lower abdominal pain - 2/3 of patients

Bloaiting, abdominal distension, gas

Changes in bowel habits, diarrhea( > 3 stools/day), constipation (< 3 stools/week with straining)

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7
Q

Alarm symptoms (red flags) of IBS

A

Blood in stools
Moderate to severe abdominal pain
Nocturnal symptoms
Progressively worsening symptoms
First incidence >50 yrs of age
Fever
Unexplained weight loss

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8
Q

Potential triggers in IBS

A

Physchiologcal factors : Anger stress

Diet: Alcohol, cafffeine,lactose,sorbitol

Hormone fluctuation with menstrual cycle

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9
Q

Diagnosis: ROME IV criteria

A

Recurrent abdominal pain at least 1 day per week during the previous 3 months associated with 2 or more of the following

  • related to defacation
  • associated with change in stool frequency
  • associated with a change in stool form or appearance

“ abdominal pain or discomfort that occurs in associated with altered bowel habits over a period of at least 3 months

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10
Q

Other investigations that are worthwhile

A

Through history: bowel movements, abdominal pain, triggers, medication history, family history

CBC/differential

Fecal lactoferrin, CRP

Serologic testing for celiac disease

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11
Q

What are the subtypes of IBS

A

IBS-D ( 40% of patients) - >25% loose stools, <25 hard stools

IBS-C (35%) - <25% loose stools, >25 hard stools

IBS-M (25%)- >25% loose stools, >25% hard stools

IBS-U ( unclassified) Variable on hard and loose stools

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12
Q

Managment of IBS : non pharmacological

A

Diet, probiotics, prebiotics, lifestyle interventions, psychological therapies

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13
Q

Managment of IBS : psychological

A

Cognitive behaviour therapy, hypnosis, biofeedback, relaxation techniques, mediation, mindfulness

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14
Q

Managment of IBS : psychological

A

Cognitive behaviour therapy, hypnosis, biofeedback, relaxation techniques, mediation, mindfulness

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15
Q

Managment of IBS: Lifestyle

A

Physical activity

Alcohol consumption

Caffeine intake ( non evidence that caffeine worsens IBS

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16
Q

Managment of IBS : Diet

A

Adequate dietary fibre - whole grains cereals, veggies, fruit

Avoid high FODMAPs food

Avoid eating large meals

Avoid food triggers

Avoid things that increase flatulence

17
Q

What is FODMAPs diet

A

Fermentable

Oligo

Di- and

Mono-saccharides

And

Polyols

18
Q

Managment of IBS: prebiotics and probiotics

A

Pre: food components remain indigestible, which stimulate either the growth or activity of colonic bacteria

Pro: live attenuated microorganisms that affect the composition and or function of gut microbiota.

Shown benefit in overall symptoms

19
Q

Managment of IBS-C (fibre supplementation)

A

Water soluble fibre first line

15-20g/day (up to 30g)

If novice start lower at 4-8g/day

May work alone

Insoluble fibre may Worsen Symptoms

20
Q

Managment of IBS-C : Osmotic Laxatives

A

Osmotic laxatives: second line

Options: PEG (first choice) or Lactulose (++gas forming)

For severe constipation or prn use for quick relief
- magnesium citrate or magnesium hydroxide
- glycerin suppositories - for immediate relief
- also : stimulants ( Bisacodyl, senna)

21
Q

Managment of IBS-C: GC-C agonists

MOA, Indications, Dose, Efficacy, Adverse effects

A

Guanylate Cyclades C agonists

MOA: Activates guanylate cyclase C receptor

Indications: moderate to severe IBS-C
- consider for patients who have not responsded to other agents for IBS-C
-Contraindications for use in children <6 years old

Dose :
-Linaclotide : 290mcg orally once daily on empty stomach
-Plecanatide: 3mg orally once daily

Efficacy:
Bowel movements frequency improves within first week, abdominal symptoms take longer

Adverse effects:
- Common; diarrhea, abdominal pain/cramping, flatulence, bloating
- rare but serious: dehydration

22
Q

Managment IBS-C : 5HT4 agonist

MOA
Indication
Dose
Efficacy
Adverse effects

A

MOA: 5HT4 Agonist , resulting in pro kinetic effect

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

Dose: pruclaopride 2mg orally once daily, eGFR <30ml/min or > 65 years old: 1 mg orally once daily

Efficacy: increase motility and transit throughout GIT, Improve QoL

Adverse effects : Common : diarrhea, nausea, GI pain, headache

Rare: But serious, Arrhythmias

23
Q

Lubiprostone

A

Derivative of PGE1
- causes activation of the intestinal chloride channel
- Enhances intestinal fluid secretion and increases GI motility

Indication: IBS-C in females
- increases spontaneous bowel movements
- reduces abdominal pain and bloating

Dose: 8mcg twice daily with food
Adverse effects: Diarrhea, bloating, nausea, abdominal pain

24
Q

Managment of IBS-D: Pharmacological strategies

A

Dietary Managment : first line
- soluble fibre : acts as a bulking agent to improve symptoms

Antidiarrheals: Second line
- Loperamide - Preferred agent
- diphenoxylate -atropine

Bile acid binding resins: if bile acid malabsorption

25
Q

Managment IBS-D: Rifaximin

MOA
Indication
Dose
Efficacy
AE

A

MOA: poorly absorbed broad spectrum antibiotic, which alters the gut microflora

Indication: More effective for IBS-D

Dose: 550mg TID x 14 days

Efficacy : Recent meta-analysis showed improvement in global IBS symptoms and bloating, may also decrease pain

AE: Minimal (N/D)

26
Q

Managment IBS-D: Eluxadoline

MOA
Indication
Dose
AE
Contraindication

A

MOA: Mu-opioid receptor agonist - acts locally in gut

Indication: Improves stool consistency/ frequency > abd pain/bloating

Dose: 75-100mg BID taken with food

Adverse effects: Nausea, Constipation, pancreatitis

Contraindication: alcohol misuse, history of pancreatitis, liver, disease, biliary duct obstruction, hx cholecystectomy

27
Q

Pain in IBS: Antipasmodic agents, anticholinergic, GI specific calcium channel antagonist

A

Anticholinergic:

Dicyclomine 10-20mg 1-4x/day,limit use, take before meals, works quickly

Hyoscine (Buscopan) 20mg QID, limit use, taken before meals, works quickly

GI specific calcium channel antagonist:

Pinaverium 50-100mg tid. AE: epigastric irritation, fullness, constipation. Take with full glass of water, and food

Antipasmodic opioid agonist:

Trimebutine 200mg tid. AE: dry mouth, drowsiness, dizziness.

28
Q

Pain in IBS: Antidepressents (tricyclic antidepressants)

MOA
Indication
Dose
Efficacy
AE

A

Tricyclic antidepreesents ( amitryptline, desipramine, imipramine

MOA: anticholinergic and analgesic effect

Indication: for patients with intractable pain

Dose: lower doses often indicated, start at lower

Efficacy: decrease abdominal pain, diarrhea, stool frequency

AE: constipation, sedation, dry mouth, blurry vision, orthostatic hypotension, urinary retention

29
Q

Pain in IBS: Antidepressants (SSRI)

MOA
Indication
Dose
Efficacy
AE

A

MOA: selectively inhibits 5HT reupatake in the presynaptic neurons and has minimal effects on norepinephrine or dopamine

Indication: may be more effective in IBS-C; use in patients with comorbid depression or anxiety

Dose:
Citalopram- 20 mg daily
Paroxetine- 20-40mg daily

Efficacy: increases GI motility, works on brain-gut axis

AE: N/D, insomnia or sedation, dizziness, nervousness, sexual dysfunction

30
Q

Pain in IBS: NHP

MOA
Indication
Dose
Efficacy
AE

A

Peppermint

MOA: Antipasmodic effect on smooth muscles

Indication: Mya reduce abdominal pain, distension
and flatulence

Dose:
Oil 0.2-0.4 ml tid before meals
Colpermin: 1-2EC capsules tid before meals

Efficacy : more data with IBS-D, however may be effective for IBS-C

AEL Heatburn, mouth ulcerations

31
Q

Summary of treatment approach for IBS

Constipation, Diarrhea, Pain

A

Constipation:
Soluble fibre (IBS-C, IBS-M)
Osomotic laxatives ( IBS-C, IBS-M)
GC-c agonist (IBS-C, IBS-M)
5HT4 agonist ( IBS-C,IBS-M)

Diarrhea: all for (IBS-D, IBS-M)
Soluble fibre
Loperamide
Eluxadoline
Cholestyramine
Rifaximin

Pain:
Antipasmodic ( all 3 types)
SSRI (IBS-C,IBS-M)
GC-c agonists (IBS-C)
TCA antidepressants ( IBS-D, IBS-M)
Eluxadoline (IBS-D)
Rifaximin ( IBS-D

PHARM 345 GI/NUTRITION (7 decks)

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