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Clinical 2.0 winter > IBS > Flashcards

IBS Flashcards

1
Q

define IBS

A

recurren abdominal pain or discomfort at least 3 days per month in last 3 months associated with:
improvement with defacation, onset associated with a change in stool frequency and appearance

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2
Q

subtypes of IBS based on the predominant stool pattern

A

with constipation
with diarrhea
mixed
unsubtypes

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3
Q

IBS pathophys

A

nervous system(brain gut interactions)
gut flora issues (post infection, bacterial overgrowth)
altered sensitivity to gut distention altered signal processes in the cns
altered motor response

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4
Q

alarm features

A 
weight loss >5kg 
bloody stool 
severe diarhea
recurring fever
over 50 (rare for onset to be in elderly)
family histoyr of colon cancer and IBD
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5
Q

what quides therapeutic plans

A

predominant symptoms

constipation, diarrhea, pain, bloating, gas

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6
Q

sources of constipation to look for

A

low fibre, lack of exercise, meds, decreased abdominal pressure, metabolic abnormalities

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7
Q

sources of diarrhea to look for

A

food
lactose
sorbitol
fructose

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8
Q

non pharms

A

establish therapeutic relationship with patient
regulate dietary intake
avoid precipitants
avoid excess - carbonated drinks, gum, caffiene

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9
Q

behavioural therapies

A 
relax
biofeedback 
hypnotherpay 
CBT
psychotherapyu
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10
Q

how long does i take to assess efficacy of treatment

A

3-4 weeks

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11
Q

treatment for IBS with constipation

A 
fiber based products
osmotic and salt laxatives
stimulant laxatives
prucalopride
linaclotide
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12
Q

fibre based products MOA

A

increase stool bulk and frequency
increase GI transit time
reduce gas by binding bile salts

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13
Q

benefit of fiber based products

A

not much better than placebo

best in abdominal pain and constipation

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14
Q

how to initiate psyllium

A

1tsp per day and increase 3-5 days

up ro 1-2 tsp 3 times a day or more

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15
Q

examples of osmotic and salt laxatives

A

lactulose (AE:gas, bloating, taste)
magnesium
phosphate
PEG based

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16
Q

describe stimulant laxatives

A

senna based , bisacodyl
quick onset
AE: cramping
dont cause colon dysfunction

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17
Q

how to approach laxatives

A

start with regimen as a regular routine then change from there

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18
Q

prucalopride MOA

A

serotonin 4 receptor agonist
lower affinity for hERG
stimulates colonic transit

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19
Q

prucalopride indication

A

chronic idiopathic constipation in females with inadequate response to laxatives

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20
Q

prucalopride disadvantage

A

renally cleared
not for pregnancy
nausea diarrhea, headache dose related
not covered

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21
Q

linaclotide MOA

A

peptide guanylate cyclse C agonist
indirectly activates cystic fibrosis transmembrane conductance regulator
secretion of CI and bicarb into bowel and increased transit

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22
Q

linaclotide disadvantage

A

diarrhea

not approved for plan coverage

23
Q

treatment steps for IBS with constipation

A

bran or psyllium — osmotic laxative magnesium —stimulant senna —- add on with lactulose or PEG — linaclotide or prucalopride for refractory

24
Q

treatments for IBS with diarrhea

A 
loperamide 
cholestyramine 
alosetron 
fiber
eluxadoline
rifaximin
25
Q

loperamide use

A

can be used prophylactically

bloating may be worsened and ab pain may develop

26
Q

describe cholestyramine use

A

3rd line role
can be used as add on
AE: taste and drug interactions

27
Q

eluxadoline MOA

A

mu opioid agonist and delta opioid receptor antagonist

min absorbtion - acts locally

28
Q

describe alosetron

A

serotonin 3 receptor antagonist
better than placebo, improves overall symptoms
major concerns with ischemic colitis lead to withdrawal, can get via approval process

29
Q

dose of fiber to increase stool consistency

A

30g/day but start lower and gradually increase

30
Q

problems with ibs studies

A

being able to compare the patient populations between studies
lack of reproduceability
much less high quality studies than other GI topics

31
Q

results of studies of obs therapies often were

A

short term response over a few weeks

very high placebo response rate

32
Q

who should be considered for drug therapy

A

wehn IBS symptoms are impacting quality of life

33
Q

fibre based products AE

A

bloating in high doses

increase gas produced in the intestines

34
Q

linaclotide efficacy

A

modest beneficial effect in ab pain and complete bowel movements

35
Q

loperamide MOA

A

increase transit time, water and electrolyte absorption and increase anal sphincter tone

36
Q

loperamide efficacy

A

improve stool consistency and ab pain over placebo

lack in decreased global symptoms and other important outcomes

37
Q

approach to treating ibs with diarrhea

A

exclude lacctose intolerance and celiac
anti diarrheals first line - loperamide
add in fiber slowly to increase stool consistency

38
Q

possible treatment for IBS with bloating and gas

A 
not likely to get beenfit from drugs 
diet
fiber
antidepressants, antispasmodics,
go for a walk after meals
39
Q

antispasmotic MOA

A

decrease pontaneous smooth muscle stimulated movements - anticholinergic or antiuscarinic

40
Q

use of antispasmodics

A

may provide relief of ab pain, distention, bloating

generally no better than placebo, odd patient swears it works

41
Q

antispasmodic AE

A

anticholinergic

tolerance

42
Q

examples of antispasmodics

A

belladona
hyoscyamine
dicyclomine

43
Q

treatment for IBS pain

A

behaviour and aversion techniques
antidepressants and nsaids for refractory
narcotics not successful

44
Q

antidepressant efficacy

A

increase pain threshold

no improvement with SSRI, modest relief with TCA

45
Q

antidepressant doses

A

chronic pain loses (low)

46
Q

antibiotic use in IBS

A

help and worsen IBS

bacterial overgrowth

47
Q

probiotics MOA

A

competition with pathogenic bacteria

antiinflammatory

48
Q

problem with probiotics

A

dont really know which ones to use and which dose

49
Q

gut floral in IBS patients

A

tend to be altered

instable

50
Q

problems with probiotics

A

GI flora anaerobic so hard to capture and grow

the bacteria are cleared from teh GI tract within a week

51
Q

problems with probiotic studies

A

small studies
no clear specific endpoint target
inter individucal variability in commensal flora
significant placebo response in trials

52
Q

what is VSL3

A

a probiotic

53
Q

how long do you have to be on probiotics for

A

indefinately because they are cleared within a week

Clinical 2.0 winter (28 decks)

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