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Irritable Bowel Syndrome: Can You Manage These Patients?

  • Authors: Charles Vega, MD; Kimberly A. Carter, DMSc, PA-C, RD; Joel J. Heidelbaugh, MD, FAAFP, FACG
  • CME / ABIM MOC Released: 11/13/2023
  • Valid for credit through: 11/13/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™

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Target Audience and Goal Statement

This activity is intended for primary care physicians, gastroenterologists, nurses, nurse practitioners, and physician assistants.

The goal of this activity is for learners to be better able to diagnose and manage IBS in their practices using the latest clinical evidence and professional guidelines.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Use of culturally competent communication to engage with patients who present with symptoms of IBS
  • Have greater competence related to
    • Diagnosing IBS based on current evidence-based recommendations
    • Creating individualized treatment plans that account for patient goals and preferences


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  • Charles Vega, MD

    Clinical Professor of Family Medicine
    Assistant Dean
    University of California Irvine School of Medicine
    Director, University of California-Irvine Program in Medical Education for the Latino Community (PRIME-LC), Family Medicine
    Irvine, California


    Charles Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson​

  • Kimberly A. Carter, DMSc, PA-C, RD

    Director of Clinical Education
    Associate Professor, Physician Assistant Program
    Midwestern University
    Glendale, Arizona


    Kimberly A. Carter, DMSc, PA-C, RD, has no relevant financial relationships.

  • Joel J. Heidelbaugh, MD, FAAFP, FACG

    Department of Family Medicine
    Director of Medical Student Education
    University of Michigan Medical School
    Ann Arbor, Michigan


    Joel J. Heidelbaugh, MD, FAAFP, FACG, has no relevant financial relationships.


  • Roderick Smith, MS

    Senior Medical Education Director, Medscape, LLC


    Roderick Smith, MS, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

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Irritable Bowel Syndrome: Can You Manage These Patients?

Authors: Charles Vega, MD; Kimberly A. Carter, DMSc, PA-C, RD; Joel J. Heidelbaugh, MD, FAAFP, FACGFaculty and Disclosures

CME / ABIM MOC Released: 11/13/2023

Valid for credit through: 11/13/2024, 11:59 PM EST


Activity Transcript

Charles Vega, MD: Hi, everyone, and welcome to this presentation from Medscape Education entitled "Irritable Bowel Syndrome," and I'm going to go ahead and call my first audible today and say you can manage these patients. I know this because I have 2 great presenters with me today. I'll introduce them momentarily.

My name is Chuck Vega. I'm a Clinical Professor of Family Medicine at the University of California at Irvine, where I also serve as Assistant Dean for Culture and Community Education.

Delighted to be joined today by Kim Carter, Director of Clinical Education and Associate Professor in the Physician Assistant Program at Midwestern University in beautiful Glendale, Arizona.

And last but not the least, Dr Joel Heidelbaugh. He's a Professor in the Department of Medicine and a Director of Medical Student Education at Michigan Medical School in Ann Arbor, Michigan. And so we have a pretty fast-moving program today.

Because we're going to cover the whole scope of irritable bowel syndrome (IBS) today. And that's kind of exciting; a little daunting because it's a very important illness, and but we are going to hit the highlights for you today.

And I think this is going to be in terms of your time, which I know is precious, uh, you're going to get a lot out of this.

So, prevalence, you know, very common, about 1 in 20 adults fit the Rome IV criteria. If you're not sure what those are, you know, don't worry, we're going to go over them very briefly with Kim.

Then there is a female predominance -- it's 2:1 -- but it's not, notably, it's not 20:1 or 10:1, it's 2:1. And so, therefore we should, you know, not necessarily dismiss, um, abdominal symptoms, bowel symptoms, uh, among males. And it is a very common reason to refer to gastroenterology as Joel well knows, but I think there's a ton we can do for these patients in primary care.

And we want to, I think, start that care, uh, and that way we have that continuity of relationship. Lots of absenteeism, actually, so in surveys, um, average of 3 days per month, uh, missed from work or school among individuals, uh, with IBS. And, of course, that results in a lot of economic costs because of lost productivity, but there's a lot of direct medical costs for patients as well.

And some of that is really, unfortunately, unnecessary going to the emergency department multiple times, getting multiple tests that really weren't necessary in the first place. So, we have a couple cases to kind of frame up some of our objectives today.

So, I'm going to introduce you to Priya. She's 40 years of age.

She's presenting with persistent constipation over the past 4 years. Symptoms are worsening after return to the office. And she has, you know, a pretty normal history without, uh, any chronic illnesses, normal body mass index. She's not using any medications. She had a complete physical exam a couple years ago, nothing really notable.

Um, wanted to make sure that we account for her social history as well. Uh, she's a partner at a major accounting firm. She's married, 2 school-aged children. Uh, she frequently travels. I think that's important to think about. And limited exercise. Doesn't smoke, but drinks socially. Um, a few alcoholic beverages per month.

Let's look at her current symptoms. She has abdominal pain that improves upon defecation. Really important to get that history specifically, and it's been going on every 2 to 4 days. She has hard stools. There's the Bristol Stool Form Scale. Uh, so 1 or 2, so those are hard, very almost like rock-like stools.

Bloating. Uh, she has symptoms, and the symptoms have worsened over the past year. Uh, she's able to work and meet deadlines at times. So there's that disability and the inability to keep up, but very importantly as well, and we'll cover this, we, she doesn't have any of the red flag symptoms -- weight loss, uh, fever, um, you know, changes in her, you know, major changes in her stool that could make us concerned.

So there is a positive diagnosis here to be made. One clear message, IBS is not a diagnosis of exclusion. Kim, do you want to walk us through this part?

Kimberly A. Carter, DMSc, PA-C, RD: Sure, thanks Chuck. You know, I think it's, we certainly have seen a paradigm shift in the diagnostic evaluation for IBS, and it's much more of a focus on a positive diagnostic strategy rather than a diagnosis of exclusion.

We know that extensive testing is of low diagnostic yield, can delay the receipt of therapy, and can increase medical costs, and doesn't necessarily reassure patients. So, clinicians, we can confidently and comfortably diagnose IBS through this positive diagnostic strategy with a few key steps and selective laboratory evaluation.

And it really begins with taking that careful, comprehensive history. So really understanding their symptomatology, their characteristics of their abdominal pain and their bowel habits. But also too, trying to identify if there's any potential etiologic association. So patients who maybe have had a previous enteritis and now maybe are presenting with a postinfectious IBS, or food insensitivities or food intolerances. And also to be considering potential traumatic events or early life stressors -- physical, emotional, or sexual abuse, -- may play a role. In addition to this, we know that the differential diagnosis for irritable bowel syndrome can be broad and can include things like celiac disease and inflammatory bowel disease.

So, ascertaining for extraintestinal symptoms -- eye pain, joint pain, rash, or oral ulcers -- can be helpful, um, to collect as part of the history. And then thinking about comorbid conditions or even medications that the patient may be on that could contribute or exacerbate constipation or diarrhea. Those are all important elements to obtain as part of the history.

Moving into the physical exam, some of our patients might have bilateral lower-quadrant abdominal pain, others may not, but certainly, the digital rectal exam can be a helpful component, especially if we're concerned about anal-rectal pathology, hemorrhoids, anal fissures, or potentially perianal Crohn disease, and a digital rectal exam can be helpful if we're concerned about dyssynergic defecation or pelvic floor dysfunction. And so the digital rectal exam can be helpful in understanding the mechanics of defecation. Applying the symptom-based Rome IV criteria can be helpful really owing to the chronicity and the frequency of symptoms. And so really gathering that information can be helpful.

Certainly want to query all of our patients for alarm features and, if present, referral to gastroenterology for further evaluation. And then lastly, this fifth step here, classifying the appropriate subtype based on their symptoms can be really helpful. Are we dealing with IBS-mixed, IBS-constipation (IBS-C) predominant, or IBS-diarrhea (IBS-D) predominant?

And so, in the case of Priya, the Bristol Stool Form Scale can really be helpful for this. That validated instrument that allows us to identify the stool pattern. Bristol Stool types 1 and 2, hard pellet stool associated with constipation, vs types 6 and 7 that can be, you know, more watery, mushy stool that can be associated with IBS-diarrhea.

So, really, IBS is not a diagnosis of exclusion, and we can utilize these 5 steps here in a selective laboratory evaluation in support of a positive diagnostic strategy.

Dr Vega: And the Bristol Scale is readily available online for, because I wouldn't necessarily have it, you know, front and center, it's not sitting right in front of me on my desk, but, yeah, it's really easy to look up and gives you a good idea and helps you track patients over time too, with something that's a little bit more objective.

Dr Carter: Absolutely. This slide here is really just a deeper dive into the Rome IV criteria. And certainly there's been iterations of the Rome criteria. But this is again owing to the chronicity and the frequency of their symptoms, really understanding their abdominal pain and their bowel habits.

And so it defines that recurrent abdominal pain on average occurs at least 1 day per week in the past 3 months and to be associated with at least 2 of the following criteria. So this could be related to defecation and oftentimes their pain may improve with defecation. Talking about associated with the change in the frequency of the stool, those patients have more frequent bowel movements, less frequent bowel movements, and then associated with the change in the form of the stool, and again, the Bristol Stool Form Scale can be helpful in this process.

But again, this criteria to be fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. So certainly helpful, um, and to be utilized in this positive diagnostic strategy.

And then lastly, alarm features. We want to query all of our patients for alarm features that could be suggestive of organic diseases and consider referral to gastroenterology for follow-up.

And so for these patients, symptoms onset greater than age 50, we want to refer for further workup. Those patients also too who have a documented unintended weight loss, 10% in the last 3 months can be concerning, blood in the stool, iron-deficiency anemia, fevers, nocturnal symptoms, acute or rapidly progressive symptoms, and important for all patients really inquiring about their family history, colorectal cancer, inflammatory bowel disease, or celiac disease. All of this is part of that comprehensive and inclusive history and consideration for the positive diagnostic strategy.

Dr Vega: I just have a word on unintended weight loss because it really does like ring an alarm bell in my head, and I get very concerned, but the first thing I do is go back and look.

I have continuity with patients. I go back and look where they were 6 months ago. Many times it's like, well, it's 2 pounds difference, but it, you know, so it's a slight weight loss, but nothing that it's, that would ring an alarm bell. So I'd really encourage, hopefully if you have continuity with patients, it makes a big difference.

Dr Carter: Absolutely.

Joel J. Heidelbaugh, MD, FAAFP, FACG: So let's now look at appropriate use of diagnostic testing based upon those IBS subtypes that Kim had started talking about there. And I'm going to start talking about how we approach patients with the mixed picture, as they may go between elements of diarrhea and constipation. The overall goal is to limit screening. The overall goal is to limit testing.

Dr Vega: Love it.

Dr Heidelbaugh: I'm going to keep out colorectal cancer screening. We're not going to cover that today. Obviously that has its own guidelines. But in the mixed picture, you can consider C-reactive protein, certainly fecal calprotectin, and, just as you would also in diarrhea- predominant patients, evaluate patients for celiac disease through tissue transglutaminase testing, immunoglobulin A (IgA) testing.

I always have patients keep a stool diary. It's probably something they don't want to talk about, but it's very useful for us because it's going to help, uh, channel and keep track of ultimately what their patterns are. The other thing we can consider is plain-film radiography to evaluate for possible stool retention and stool burden.

And that can also be useful in patients with constipation-predominant.

In the patients with constipation-predominant, I'm going to highlight this -- this is probably the group that doesn't require a lot of special testing. And if what's happening is ultimately very severe or medically refractory, we're going to get into treatment again in a few minutes here.

That's when we really think about, referring to gastroenterology. Kim, you had mentioned some physiologic testing, evaluation for defecatory disorders and dyssynergic defecation as well.

Dr Vega: So, let's go back to Priya for a second. So, the test performed for her, you remember her case, 40 years of age, and, we would just get a complete blood count (CBC).

You know, it's a good test because certainly I didn't detect that she had any red flag symptoms, but the CBC, if she has significant anemia, or, you know, very elevated white count, I'd want to investigate those things further. So, guess what? We can proactively diagnose her with IBS-C. So, great news. And so, what are we going to recommend?

What about some of the nonpharmacologic treatments that we might approach? Since these lifestyle, I think, work for a lot of folks, and obviously they're just good recommendations overall. Physical activity definitely can help move bowels in IBS-C. Um, we also really want to take a look in -- are we mistreating our patients?

Are we causing iatrogenic harm, particularly with anticholinergic drugs, you know. And so, for IBS-D, we could consider using tricyclic antidepressants as, you know, as something that could help both with mood and with our bowel symptoms. But you absolutely want to stay away from those kinds of that class of drugs in IBS-C.

Diet and fiber intake. So we're going to talk a lot about diet. I know we're covering FODMAP diet for IBS-D in a little bit, but with IBS-C still makes a difference. Plant based, lots of fiber, soluble fiber, very, very important. So there's a question about artificial sweeteners and can they, um, aggravate IBS?

Absolutely, that's an insoluble compound, so it can make it a lot worse. So people who are using a lot of, you know, diet, um, gum or mints or things like that, you know, it's sorbitol. Those kinds of products are available in a lot of different foods. So, uh, so yeah, instead focus on the fiber intake.

And then there's, uh, there's definitely a role, and this is something we can readily do in primary care, start treating for constipation. So, you know, you can initiate treatment, um, with some very basic generic and sometimes even over the counter medications are worth a try. And, uh, I think, I will hand it back to you, Joel, as an expert to go over some of those, uh, treatment options.

Dr Heidelbaugh: Sure. So, I always try to start by, um, ascertaining what a patient has already tried or what they may already be taking, what they bought over the counter, etc. And everybody's very familiar with fiber and all of its very types. Chuck pointed out the importance of soluble fiber. And it has been shown to give some modest benefits for global IBS symptoms.

You have to be careful though, because a lot of times if patients are not used to taking fiber, we recommend fiber, they overdo it on the fiber. Now they're going to get a lot of bloating and cramping.

Dr Vega: Too much is too much.

Dr Heidelbaugh: Too much is too much, especially too quick. And there is a strong recommendation by the American College of Gastroenterology (ACG) for overall symptomatic improvement.

Fiber is low cost. Um, there's usually a lack of significant side effects, and there are other health benefits as well.

Let's jump to osmotic laxatives because I find a lot of our patients use these as well. Again, readily available over the counter. Polyethylene glycol, certainly one of the most common and readily available.

Lactulose, magnesium citrate, minus, of course, the national shortage that we're experiencing right now, but another great osmotic laxative. And these have been shown to improve stool frequency and consistency. But they don't necessarily reliably improve abdominal pain or bloating. And so, I always separate those out between symptoms and stool form inconsistency, as we all do and we should.

The ACG has given polyethylene glycol a weak recommendation against its use for overall symptom improvement in IBS for those reasons.

And then stimulant laxatives, again, another very common and readily utilized formulation -- senna, cascara sagrada, castor oil, uh, tastes much better than it used to if you took it as a kid, bisacodyl. ACG makes no recommendations about these regarding stimulant laxatives and their improvement in outcomes. And there are no randomized clinical control trials on these, but they do appear to have been conducted for some elements of IBS-C. Let us now I'm going to talk about FDA-approved medications for IBS-C and chronic idiopathic constipation (CIC).

Again, going back to that element that you highlighted with the Rome IV criteria, the biggest determining factor there is -- abdominal pain and pain relief with defecation, which is different from CIC. This is a busy slide. I'm not gonna read every word on it, but I use this as a great reference in my practice as you may as well. We start with lubiprostone as a type 2 chloride-channel activator and linaclotide as a guanylate cyclase C-receptor agonist.

These have great indications for IBS-C/CIC, and then lubiprostone also has an indication for opioid-induced constipation (OIC). Prucalopride, again, a guanylate cyclase C-receptor agonist, similar to linaclotide, also has indications for IBS-C and CIC. Newer medications like prucalopride, which is a highly selective serotonin receptor agonist, and tenapanor, which inhibits NHE3. These also have utilization again for CIC and IBS-C. The common adverse effects are listed here I'm not going to read through all of these. I think it's important to know that you probably see that many of them are predicated upon diarrhea or nausea So what are we treating?

We're treating constipation. We're treating both the chronic forms and the IBS-C forms. We'll talk about dosing here in a minute, but we want to be cautious about nausea. We want to be cautious about diarrhea. And then some of them have also been linked to flatulence and abdominal pain and ultimately worsening of symptoms.

Dr Vega: What do you think about the safety? It's great discussion of tolerability. Very important to warn patients upfront about some of the side effects, even for those over the counters. That was a great point on the psyllium. But what about safety? Is there significant safety signals, bowel ischemia, or other significant problems that we should be concerned with before prescribing these agents?

Dr Heidelbaugh: It's a great question. I get asked this a lot. The great news is -- no, this has not been reported. You know, there were, there were other agents in the past where that was certainly a concern. Alosetron was certainly implicated in that and then came back. The Black Box warning was removed. But these appear to be much safer.

And as time goes by, I also believe they will hopefully become more readily available for our patients as well.

This slide highlights prescription secretagogues for IBS-C, and the indications and dosing. So with lubiprostone, IBS-C indicated in women 18 years of age and older, CIC for adults, and also OIC (opioid-induced constipation).

Dosing generally will start with 8 mg, excuse me, 8 µg, twice daily, for IBS-C. And then for CIC and OIC, it'll be 24 µg, twice daily. You want to take this medication with food and water? With linaclotide, IBS-C and CIC, again, adults 18 years of age and older.

Functional constipation, it also has an indication for pediatric patients 6 to 17 years of age. Dosing for IBS-C is 290 µg, once daily, and CIC, I'll start at 72. I start lower, try to build up as you need to, but 72 µg up to 145, once daily. And then functional constipation, 72. You wanna take this one on an empty stomach. Different from lubiprostone and at least 30 minutes before the first meal of the day.

So that's that important distinction there. Plecanatide, IBS-C and CIC in adults 18 years of age and older is the indication, 3 mg, orally, once daily. It's contraindicated in pediatric patients under 6 years of age. This one you can take with or without food.

Dr Vega: All right, so We'll take a quick break.

That was a great discussion of IBS-C. And before we switch to IBS-D, it's very important, we all work in multicultural settings, and we see patients who have different concerns, bringing different values, and certainly have different patterns in terms of their health habits, their diet. And we want to make sure we're addressing those in a way that's sensitive.

So, just a quick primer, I'd love your input, but, you know, always reflect empathy and understanding. IBS patients are definitely discriminated against. There's a bias against IBS patients in the healthcare community, and because they're seen as, well, they're complaining a lot, there's no real pathology there, you know, this is all in their head. And those aren't true.

And that's why I think, you know, we're one of the reasons we're here to talk about this, though, when you do that outreach and you listen with empathy, maybe you're the first 1 out of the last 4 providers has actually done so. You can really start to make a difference. And so you want to use empathic statements, while that sounds really difficult, but I always pair that with.

But you know what, we have some therapies that can make you feel a lot better. So you really want to recognize that they may be down, they may be depressed. There's a strong mental health connection as we're going to talk about. And the use of antidepressants is indicated among many folks who have comorbid depression or anxiety disorders associated with IBS. But you still want to lift them up at the end. And I really liked your, your comment, Kim, about using trauma informed care, you know, asking permission. So I usually start the conversation by just asking, what do you think is going on here? Is there anything that, what makes it worse?

And, you know, anything you're really concerned with. So give them a space there. Is it okay if we talk about, you know, any history of trauma that you may have suffered in your life? For a lot of my patients, they don't even know that; that doesn't get them to, what you know to, actually think about the question, but then I'll provide some examples -- somebody around you who is killed, you know, tragically and you actually had to witness it, or some act of violence against you or abuse. And then if your patient's comfortable, they will open up, and that can, help with a whole bunch of different issues.

And you know, including IBS. So it's worthwhile. And then the cultural cues, think back to Priya's case, you know, she may have a very different diet at home than she is, she's on the road, which of those is triggering for her? And so, you know, finding some balance there may be a really good idea for someone like Priya.

So it comes down to listening to your patients, starting with your patients. It's their story. Let them tell it. You are there to explain your perspective. But then you, I'm pretty clear about acknowledging differences and that way we have a negotiation, and we talk about, you know, where we can meet in the middle here.

At that point we, I actually usually agree. I love it when patients develop their own plan of care essentially because they're automatically bought into it. They're the ones who developed it. They know their opportunities and challenges far better than I do. And so I think that, and that, using that shared decision-making model is really important and is ultimately going to yield better outcomes, particularly for a more sensitive issue like IBS, where patients oftentimes feel biased stigma.

And look at the popular media. It gets made fun of all the time and, you know, you know, but, you know, we're talking about 5% of the population, you know, why would you want to, you know, take that kind of abuse? So, any other comments before we move on?

Dr Carter: I think it's important just to be able to have, you know, bi-directional communication, one that's inclusive and really, um, is free of any sort of assumptions of similarities.

And so, um, acknowledging their, their health benefits and their dietary practices and culinary practices, I think that can be very helpful in coming up with a supportive plan of care that can be helpful.

Dr Vega: Yeah. And I think you, you really want to find out what's valuable that way and, and that might be the last thing you, you try to address, even if you realize like, ah, that sounds like a lot of rich food and it could be, you know, potentially making these things worse, but if it's like the, the big family dinner that happens once a week where everybody's there, it's going to be, my experience is very hard to touch that, but you know, you can get there, make some other smaller, easier changes, the low-hanging fruit, and then work towards something bigger in the end.

Okay. Let's talk about Simon. Simon is our next case. So he's 25 years old and he's playing with complaints of abdominal pain and diarrhea. Started about a year and a half ago. Symptoms are very disruptive to his job. Um, he is a flight attendant. So that, that, that makes sense. He's generally been healthy.

No history of organic gastrointestinal (GI) diseases. I asked about family history too. I think that's important. Um, single, no children. Flight attendant, poor sleep. That's not going to help. Eats poorly. Lots of fast food at airports. That's going to be a challenge. Does not drink alcohol. And getting a little drilling down a little bit more on his symptomatology.

He has 3 to 4 loose stools per day. Um, it's that Bristol scale of 6 to 7. Um, and it's often accompanied by crampy abdominal pain. So this is a daily issue for him, and he's self medicating with loperamide, which isn't the end of the world, but, um, but maybe we could think about doing better for him.

And, uh, Kim, yeah, what do you think about IBS-D and the workup we might pursue there?

Dr Carter: So certainly, similarly in the event of getting a CBC to assess for anemia or leukocytosis and that age-appropriate colorectal cancer screening, but what differs a little bit here in patients between IBS-C and IBS-D is the differential diagnosis including things of inflammatory bowel disease, Crohn or ulcerative colitis, celiac disease, and potential infectious diarrhea. So a C-reactive protein, fecal calprotectin, although nonspecific markers if elevated could suggest more potentially inflammatory components. Um, the tissue transglutaminase (tTG) plus or minus a total IgA level if there is concerns for deficiency, can be helpful for the evaluation of celiac disease, and if positive, proceed forward.

And then a Giardia antigen assay. Certainly in patients who have a high pretest probability, this could be considered, as well as other stool tests. Um, certainly if patients have food-borne outbreaks or community exposures, prior antibiotic use or, you know, travel to endemic areas, those things can be considered as well as part of your workup for a patient with IBS-D.

Dr Heidelbaugh: Let's briefly talk about some of the categories of IBS-D therapy, and this slide breaks everything down by mechanism of action, which is really, uh, convenient in terms of organization. So, if you take a look at how different medications modulate gut flora, we, we talk about rifaximin, we talk about probiotics.

I'm going to have a slide on FODMAP diet in a few minutes. Bile acid binding agents, uh, there's a percentage of patients who we might think have IBS-D who actually have bile acid, uh, malabsorption, that's a separate issue, but the binding agents include the cholestyramine, colestid, colesevelam.

colocebulin. Antispasmodics we use, peppermint oil. I'm going to make a plug that it should be enteric coated because if it's not enteric coated, they worsen gastroesophageal reflux disease (GERD). We also use dicyclomine and hyoscyamine. The serotonin antagonist, the 5HT3 antagonist, we use olocitron and ondansetron. Ondansetron, a very common antinausea medication, also has a strong indication for IBS-D therapy.

We use opioid-receptor modulators. We use diphenoxylate, eluxadoline, and loperamide. And then we do a lot with neuromodulation, certainly because of the visceral hypersensitivity, the relationship between serotonin and the gut, the disorders of the gut-brain interaction and axes we commonly talk about.

We use antidepressants, often the tricyclics and the selective serotonin reuptake inhibitors (SSRIs), and also gut-directed behavioral therapy is also very effective.

This is a slide, this is a very busy slide on FODMAP. We could have a very long conversation on FODMAP, but I'm going to try to summarize it in 1 slide. I try to tell people to think about the FODMAP diet in terms of it being an elimination diet, and it should not be a long-term diet.

Guidelines recommend somewhere between 4 to 6 weeks. This is not the DASH (Dietary Approaches to Stop Hypertension) diet where you hand your patient a pamphlet and say, stop using sodium, okay? FODMAP, I try to highlight the foods and the different elements of the foods relative to breakdown components. I'm not going to read each of these, but as you can see, many of us eat many of these every day.

I have a large percentage of vegans and vegetarians in my practice. I'll show them this and they look at me and say, well, what am I supposed to eat? So it's not about eliminating everything. It's about eliminating things one at a time. And why is that? Because many of these foods and food substances may ultimately have some impact on motility.

They may have an impact on visceral sensation and hypersensitivity as well really as immune activation, okay, and ultimately gut permeability. So busy slide. I think the take-home point of this is know your dieticians well, utilize your resources, and explain to people that this is an elimination diet and, you're going to work through it with them.

Talk about rifaximin quickly. This is a slide that summarizes pooled safety analysis, and it demonstrated really no significant difference between rifaximin and placebo relative to adverse effects. I think rifaximin has gotten a very negative connotation over the years as being a very strong drug with a lot of adverse effects.

We can use it in dosage for treatment of IBS-D, 550 mg, 3 times a day, for 14 days. And there is an indication now to use it as a recurrence for up to 2 additional treatments in the event that the patient's symptoms do not improve. They've highlighted here very nicely on the tabulation many of the adverse effects, and again you can see that there's not a substantial difference between, um, rifaximin and placebo, so fairly well tolerated.

For eluxadoline, this drug, uh, really has revolutionized a lot of the therapy for, IBS-D. And, uh, we see a lot of this in primary care. I think, um, a number of primary care docs use it as well. The dosage is between 100 mg twice daily taken with food or 75. You can use the lower. Many of us will start with the lower as well for patients who either might not be able to tolerate it or have some mild or moderate hepatic impairment. I recommend getting a comprehensive panel and checking liver function and renal function baseline before starting this drug. It's contraindicated in patients who have had a cholecystectomy, bile duct obstruction, any type of sphincter of Oddi dysfunction or disease.

Definitely contraindicated in patients with a history of pancreatitis, and I will also find out how much they drink on a regular basis. I'll ask them, they'll tell me, and then I'll say, if I give you this medication and you drink a certain amount, you're probably going to have problems as well. And then certainly contraindicated in severe constipation.

Dr Carter: So we're going to round off with finishing up with a little bit of some complimentary and adjunctive treatments for IBS.

Um, certainly the, role of the gut microbiome in irritable bowel syndrome has, um, spurred interest in the utility of probiotics to help modulate the gut flora. And it can be helpful for patients with bloating and gas less effective for changes in their bowel habits or abdominal pain.

There are some challenges with probiotics. There's variance in preparation and dosages and strands, so it makes it hard to provide definitive recommendations. But certainly for those patients that do trial probiotics, using for a 2 to 3 month period over the course, or as compared to on an as needed basis may be helpful.

But probiotics are also found naturally in foods that offer nutrient-rich properties as well and health benefits. So, taking that into consideration is important.

We've talked already a little bit about neuromodulators, antidepressants, tricyclics, and SSRIs that can be helpful in the management of irritable bowel, or yes, irritable bowel syndrome, um, and can be helpful with that pain predominant symptomatology, the visceral hypersensitivity.

We don't have a lot of strong evidence, but certainly mechanistically, they do work to exert an antidepressant action, visceral analgesia, changes in motility and smooth muscle relaxation. In particular, the tricyclics can be helpful for patients who have irritable bowel syndrome, diarrhea. But we do know the ability to escalate the dose therapy on that can be limited by anticholinergic side effects. So, um, considering that, and then the final piece of this here is psychotherapies.

Certainly our advances in understanding the brain-gut axes and advances in neural behavioral sciences, they've really paved the way for psychotherapies in the management of IBS. And this includes mindfulness, this includes relaxation techniques such as diaphragmatic breathing, can include cognitive behavioral, hypnotherapy, and all are really designed to help reframe, um, our thought processes, self-coping mechanisms, self-regulation techniques.

And we do know that cognitive behavioral therapy can be helpful in improving symptoms and quality of life. It does require a lot of time-intensive counseling and, you know, a strong patient-provider relationship. The success of that can really depend on that. Its use, unfortunately, is limited by a lack of available skilled therapists.

And so we're really at a new era in the fact that we have some app and web-based options emerging to help bridge this gap and to get individuals the therapy they need.

So this slide highlights some of the cognitive behavioral digital therapeutics that are available specifically for IBS. We have Mahana IBS and Zemedy.

Mahana is FDA cleared with prescription required. Zemedy is not FDA cleared with no prescription required. They differ a bit in their number of sessions and their duration of therapy, but ultimately they are designed to provide a personalized, self-placed, uh, plan that really targets that biopsychosocial, emotional, behavioral, physiologic responses of IBS.

And allows patients to track their symptoms, dietary patterns, defecation habits, their thought processes, and really offering, you know, psychoeducation, relaxation techniques to help improve their, uh, quality of life and their symptoms. So, certainly, um, emerging and can be helpful for, for patients to help manage their symptoms.

Dr Vega: Alright, well that was amazing. Thanks to both of you for taking us through a really whirlwind but important tour that I think really hit the highlights, including that IBS is a chronic functional bowel disorder.

It's a rea disease entity, and it causes a lot of suffering and reductions in health-related quality of life, absenteeism.

Real problems. And so you want to, I think those Rome IV criteria make a lot of sense to me. I don't think it takes a long time to apply them. You know, again, if you, if you can't remember exactly what those criteria are, they're very easy to find online. And then once you find IBS-C and you make that positive diagnosis, you want to initiate treatment.

Treatment with lifestyle is foundational, treatment with diet. Um, but then, uh, yeah, use medications. And go ahead and use some of the prescription medications. As we described, they're generally well tolerated. Uh, they're very, uh, they're very safe and, uh, and you can really make a significant difference.

You can really change patients' lives. If they have residual mental health symptoms, you want to treat those simultaneously. Many times I see the IBS drug and the antidepressant usually is what we're using, um, work hand in hand, and over the course of a couple months really makes a difference for folks.

And then if those things are not working and you're really struggling or the diagnosis maybe isn't a little bit of doubt. Um, yeah, definitely get GI involved, and I think that that is the time, I, what do you think as, as, you know, you work in specialty practices, seems like that's the time to refer on and give you something a little bit more challenging to, to work with, as opposed to a patient with more moderate symptoms who responds well to therapy.

What's your opinion?

Dr Heidelbaugh: I agree. I think, you know, I, like you said, I try to elicit what the patient has certainly tried, what's worked, what has not worked. I think this is about building a level of comfortability with the therapies we've talked about today and the medications we've talked about today.

The other plug I'll make is in primary care practices, everybody respects how busy primary care physicians are. I will take a patient with either known or suspected IBS, and I'll say we're going to dedicate an entire visit to this because it deserves that. And it's going to need longitudinal follow up.

Dr Carter: And I think that's a great point. I think that continuity of care is really important. And sharing with the patient that this is something that we're going to work through over the next several visits to help, to help support you. That's important.

Dr Vega: And I'm just going to anticipate what some, some of our viewers are thinking is like, well, but yeah, these medications can be expensive.

They're hard to get, you know, covered by insurance. But if you take the steps to make the diagnosis and you document those and then you start on therapies and you start on lifestyle and you start on, you know, maybe some generic therapy, um, you will find, I think that your prior authorization kind of writes itself and, uh, it's much more likely to be successful.

And I think that's another good thing to establish as a track record for, for patients if, if you're going to refer them off.

And I just want to say, uh, on behalf of my esteemed colleagues here, thank you very much for attending this presentation. We know how busy you are in clinical practice, and hopefully you find that this was helpful and very pragmatic, uh, to help you take better care of patients.

Thank you very much again, and be well.

This transcript has not been copyedited.

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