Treatment

Question 1

What is the treatment for IBS?

Answer 1

Focus on controlling symptoms, initially using lifestyle/dietary measures, then cognitive therapy or pharmacotherapy.

Question 2

How are changes in bowel habits managed in IBS?

Answer 2

• Constipation: ensure adequate water and fibre intake and promote physical activity. Can try simple laxatives and then prucalopride, linaclotide or lubiprostone
• Diarrhoea: avoid sorbitol sweeteners, alcohol and caffeine, reduce dietary fibre content, encourage patients to identify trigger foods

Question 3

How are other symptoms in IBS managed?

Answer 3

• Colid/bloating: oral antispasmodics - mebeverine or hyoscine butyl-bromide. Combination probiotics may help flatulence or bloating
• Psychological symptoms/visceral hypersensitivity: over time, symptoms begin to improve but can consider CBT, hypnosis and tricyclics.

Question 4

What is the 1st line pharmacological treatment in IBS?

Answer 4

• Antispasmodic alongside dietary and lifestyle advice
• Consider offering laxatives (discourage lactulose)
• Offer loperamide as first choice of antimotility agent for diarrhoea
• Advise patient how to adjust dose according to response e.g. stool consistency

Question 5

What is the 2nd line pharmacological treatment in IBS?

Answer 5

• Consider linaclotide only if optimal or max tolerated doses of previous laxatives from different classes have helped AND they have had constipation for at least 12months
• Follow up after 3 months - TCAs then SSRIs

Question 6

What is the 3rd line pharmacological treatment in IBS?

Answer 6

Eluxadoline for treating IBS with diarrhoea, only if:

• Condition hasn’t responded to other pharmacological treatment
• Pharmacological treatments are contraindicated or not tolerated AND
• It is started in secondary care
• Stop after 4 weeks if inadequate relief of symptoms of IBS with diarrhoea

Question 7

What is the treatment for infectious diarrhoea?

Answer 7

• Most infectious diarrhoea is self-limiting and does not requite antibiotics
• Fluid management, including oral rehydration

Question 8

What is the treatment for mild UC?

Answer 8

• Mesalazine is mainstay for remission-induction/maintenance. Give PR for distal disease and PO for more extensive.
• Topical steroid foams PR e.g. hydrocortisone

Question 9

What is the treatment for moderate UC?

Answer 9

If 4-6 notions/day but otherwise well, induce remission with oral prednisolone.

Question 10

What is the treatment for severe UC?

Answer 10

• If unwell + >6 motions/day admit for IV hydration/electrolyte replacement, IV steroids e.g. hydrocortisone, rectal steroids, VTE prophylaxis
• Monitor temperature, pulse and BP - record stool frequency/character on stool chart
• Twice daily exam: distension, bowel sounds, tenderness
• Daily FBC, ESR, CRP, U+E and AXR
• IF on day 3-5 CRP >45 or > 6 stools/ day, then action rescue therapy with ciclosporin or infliximab
• If fails to improve then urgent colectomy by day 7-10

Question 11

What therapies are used in Crohn’s disease?

Answer 11

• Azathioprine used if refractory to steroids, relapsing on steroid taper or requiring >2 steroid courses/yr.
• 5-ASA: unlike in UC, have no role in management of Crohn’s
• Biologics: anti-TNF alfa, anti-integrin, anti IL12/23
• Nutrition: enteral is preferred, consider TPN as last resort