IBS

Question 1

define IBS

Answer 1

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

Question 2

subtypes of IBS based on the predominant stool pattern

Answer 2

with constipation
with diarrhea
mixed
unsubtypes

Question 3

IBS pathophys

Answer 3

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

Question 4

alarm features

Answer 4

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

Question 5

what quides therapeutic plans

Answer 5

predominant symptoms

constipation, diarrhea, pain, bloating, gas

Question 6

sources of constipation to look for

Answer 6

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

Question 7

sources of diarrhea to look for

Answer 7

food
lactose
sorbitol
fructose

Question 8

non pharms

Answer 8

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

Question 9

behavioural therapies

Answer 9

relax
biofeedback 
hypnotherpay 
CBT
psychotherapyu

Question 10

how long does i take to assess efficacy of treatment

Answer 10

3-4 weeks

Question 11

treatment for IBS with constipation

Answer 11

fiber based products
osmotic and salt laxatives
stimulant laxatives
prucalopride
linaclotide

Question 12

fibre based products MOA

Answer 12

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

Question 13

benefit of fiber based products

Answer 13

not much better than placebo

best in abdominal pain and constipation

Question 14

how to initiate psyllium

Answer 14

1tsp per day and increase 3-5 days

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

Question 15

examples of osmotic and salt laxatives

Answer 15

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

Question 16

describe stimulant laxatives

Answer 16

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

Question 17

how to approach laxatives

Answer 17

start with regimen as a regular routine then change from there

Question 18

prucalopride MOA

Answer 18

serotonin 4 receptor agonist
lower affinity for hERG
stimulates colonic transit

Question 19

prucalopride indication

Answer 19

chronic idiopathic constipation in females with inadequate response to laxatives

Question 20

prucalopride disadvantage

Answer 20

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

Question 21

linaclotide MOA

Answer 21

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

Question 22

linaclotide disadvantage

Answer 22

diarrhea

not approved for plan coverage

Question 23

treatment steps for IBS with constipation

Answer 23

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

Question 24

treatments for IBS with diarrhea

Answer 24

loperamide 
cholestyramine 
alosetron 
fiber
eluxadoline
rifaximin

Question 25

loperamide use

Answer 25

can be used prophylactically | bloating may be worsened and ab pain may develop

Question 26

describe cholestyramine use

Answer 26

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

Question 27

eluxadoline MOA

Answer 27

mu opioid agonist and delta opioid receptor antagonist | min absorbtion - acts locally

Question 28

describe alosetron

Answer 28

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

Question 29

dose of fiber to increase stool consistency

Answer 29

30g/day but start lower and gradually increase

Question 30

problems with ibs studies

Answer 30

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

Question 31

results of studies of obs therapies often were

Answer 31

short term response over a few weeks | very high placebo response rate

Question 32

who should be considered for drug therapy

Answer 32

wehn IBS symptoms are impacting quality of life

Question 33

fibre based products AE

Answer 33

bloating in high doses | increase gas produced in the intestines

Question 34

linaclotide efficacy

Answer 34

modest beneficial effect in ab pain and complete bowel movements

Question 35

loperamide MOA

Answer 35

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

Question 36

loperamide efficacy

Answer 36

improve stool consistency and ab pain over placebo | lack in decreased global symptoms and other important outcomes

Question 37

approach to treating ibs with diarrhea

Answer 37

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

Question 38

possible treatment for IBS with bloating and gas

Answer 38

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

Question 39

antispasmotic MOA

Answer 39

decrease pontaneous smooth muscle stimulated movements - anticholinergic or antiuscarinic

Question 40

use of antispasmodics

Answer 40

may provide relief of ab pain, distention, bloating | generally no better than placebo, odd patient swears it works

Question 41

antispasmodic AE

Answer 41

anticholinergic | tolerance

Question 42

examples of antispasmodics

Answer 42

belladona hyoscyamine dicyclomine

Question 43

treatment for IBS pain

Answer 43

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

Question 44

antidepressant efficacy

Answer 44

increase pain threshold | no improvement with SSRI, modest relief with TCA

Question 45

antidepressant doses

Answer 45

chronic pain loses (low)

Question 46

antibiotic use in IBS

Answer 46

help and worsen IBS | bacterial overgrowth

Question 47

probiotics MOA

Answer 47

competition with pathogenic bacteria | antiinflammatory

Question 48

problem with probiotics

Answer 48

dont really know which ones to use and which dose

Question 49

gut floral in IBS patients

Answer 49

tend to be altered | instable

Question 50

problems with probiotics

Answer 50

GI flora anaerobic so hard to capture and grow | the bacteria are cleared from teh GI tract within a week

Question 51

problems with probiotic studies

Answer 51

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

Question 52

what is VSL3

Answer 52

a probiotic

Question 53

how long do you have to be on probiotics for

Answer 53

indefinately because they are cleared within a week