NICE guidelines february 2008 Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care NICE guidelines february 2008

Why develop IBS guidelines ? distinguish organic from functional disease encourage early +ve diagnosis minimize investigations evidence based management aid appropriate referral to GI clinics limit referrals to non-GI specialists reduce excess rates of surgery in IBS raise awareness of existing IBS resources better information and advice for patients  improve patient care and reduce costs

Introduction Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders, with a prevalence estimated between 10 and 20%. People present to primary care with a wide range of symptoms, some of which overlap with other gastrointestinal disorders The key elements of management are: establishing a positive diagnosis identifying symptoms that require prompt referral working in longterm partnership with the patient

Initial Presentation a person reports having had any of the following symptoms for at least 6 months: A bdominal pain or discomfort B loating C hange in bowel habit

Positive diagnostic criteria for IBS consider diagnosing IBS only if the person has abdominal pain or discomfort that is: relieved by defaecation, or associated with altered bowel frequency or form and at least 2 of the following: altered stool passage bloating, distension, tension or hardness symptoms made worse by eating passage of mucus supportive non-gastrointestinal symptoms

Multiple non GI symptoms support a diagnosis of IBS headache low backache fibromyalgia thigh pain lethargy poor sleep urinary frequency dyspareunia nausea early satiety  avoid referral to many different specialists

In people who meet the diagnostic criteria carry out the following tests to exclude other diagnoses: full blood count (FBC) ESR or plasma viscosity c-reactive protein (CRP) antibody test for coeliac disease (TTG) (stool culture, faecal inflammatory markers)

In people who meet the diagnostic criteria Do not do the following tests to confirm a diagnosis of IBS: ultrasound rigid/flexible sigmoidoscopy colonoscopy or barium enema thyroid function tests stool ova/parasites faecal occult blood hydrogen breath test

Symptoms requiring referral to secondary care If any of the following red flag symptoms: unintentional/unexplained weight loss rectal bleeding family history of bowel or ovarian cancer In people aged over 60, a change in bowel habit lasting more than 6 weeks with looser and/or more frequent stools.

Signs requiring referral to secondary care assess and clinically examine people with possible IBS symptoms and refer if any of the following ‘red flags’ are found: anaemia abdominal masses rectal masses inflammatory markers for IBD If symptoms suggest ovarian cancer consider performing a pelvic examination

Lifestyle: diet and physical activity provide information about self-help encourage time for leisure and relaxation assess physical activity levels (GPPAQ) assess diet and give general advice review fibre intake and adjust accordingly take probiotics according to the manufacturers instructions for a trial of at least 4 weeks discourage the use of aloe vera

Randomised controlled trial of self-help interventions in patients with a primary care diagnosis of IBS Self-help guidebook (diet, lifestyle, drugs & alternative therapies) baseline 1 year 1 2 3 4 5 GP visits per year usual care (n=141) usual care plus guidebook (n=140) average reduction in GP visits over the trial year = 1.56 (1.98-1.15), p = 0.001 improves coping with rather than symptom severity first line treatment for patients with functional bowel symptoms in primary care ? Robinson et al, Gut 2006

The Gut Trust is a UK national charity offering advice information and support @ www.theguttrust.org members benefits include: online self-help management programme. fact sheets on all aspects of IBS IBS telephone helpline staffed by trained nurses support from others with IBS practical advice and hints on living with IBS Gut Reaction quarterly magazine

General dietary advice have regular meals and take time to eat avoid missing meals or long gaps between eating drink at least 8 cups of fluid per day restrict tea and coffee reduce intake of alcohol and fizzy drinks consider limiting intake of high fibre food reduce intake of resistant starch for diarrhoea avoid sorbitol for wind and bloating consider oats

Probiotics and IBS B. infantis 35624 (1x108 cfu) vs placebo Whorwell et al Am J Gastroenterol 2006 B. infantis 35624 (1x108 cfu) vs placebo 362 females with IBS (Rome II) improved abdo pain/discomfort after 4 weeks (p=0.2) improved other IBS symptoms and global relief available as Align™ capsules (Proctor & Gamble) VSL#3 (Ferring) sachets containing live lactobacilli and bifidobacteria can be ordered by local pharmacy (£13.95/pack of 10)

First line pharmacological treatment choose single or combination medication based on the predominant symptom(s) consider antispasmodics - these should be taken PRN alongside dietary and lifestyle measures offer laxatives for constipation but discourage use of lactulose offer loperamide as the first choice anti-motility agent for diarrhoea adjust he dose of laxative or anti-motility agent according to stool consistency (bristol type 4)

Second line pharmacological treatment consider tricyclics for their analgesic effect start at a low dose (5-10mg equivalent of amitriptyline) taken once at night and review regularly - the dose may be increased but should not usually exceed 30mg. consider SSRI’s only if tricyclics are ineffective take into account the possible side-effects of tricyclics and SSRI’s. if prescribing for the first time follow up at 4 weeks and then every 6-12 months

Follow-up agree follow-up with the person based on symptom responses to interventions. this should form part of the annual patient review investigate or refer to secondary care if ‘red flag’ symptoms appear during management or follow-up.

Referral for psychological interventions for people with refractory IBS who do not respond to pharmacological treatments after 12 months, consider referring for: cognitive behavioural therapy (CBT) hypnotherapy psychological therapy do not encourage the use of acupuncture or reflexology for the treatment of IBS

GUIDELINES FOR THE MANAGEMENT OF FUNCTIONAL LOWER GI DISORDERS IN PRIMARY CARE 1. Investigation of colorectal symptoms: If anaemic check ferritin/folate/B12 to confirm cause. Screen for coeliac disease in patients with diarrhoea using transglutaminse antibody (TTG). Stool cultures if acute diarrhoea (<6 weeks) particularly if there are risk factors. 1 in 10 people with bacterial gastroenteritis develop post-infectious IBS. Exclude clostridium difficile if recent antibiotic use Alarm features – always refer to the colorectal cancer guidelines as first priority New colorectal symptoms in patients  45 years, rectal bleeding, iron deficiency anaemia, abdominal or rectal mass, significant unintended weight loss, family history of colorectal cancer. Also refer to alarm features in the IBD guidelines ROME III criteria Abdominal pain or discomfort for at least 3 days per month in the past 3 months associated with at least two of the following: (1) relieved by defaecation (2) onset associated with change in stool frequency (3) onset associated with change in stool consistency The presence of multiple non-gastrointestinal symptoms increases the likelihood of a functional diagnosis headaches, poor sleep, chronic fatigue, fibromyalgia, low back pain, thigh pain, gynaecological or urinary symptoms, nausea and dyspepsia. Avoid referring to multiple specialists if these are present. Presentation to GP with colorectal symptoms 2. history abdominal and rectal examination 3. full blood count in all patients If diarrhoea consider CRP , coeliac antibodies and stool culture 1 patients aged 18-45 years with NO alarm features 2 4. pain bloating diarrhoea constipation diverticular disease drug-induced bowel obstruction/adhesions functional dyspepsia gallstones lactose intolerance microscopic colitis bile salt malabsorption slow transit constipation pelvic floor dysfunction gynaecological disorders small bowel bacterial overgrowth pancreatitis assess ROME 3 criteria 3 POSITIVE make a positive diagnosis of IBS NEGATIVE functional disorder still highly likely but consider other diagnosis 4 5. General therapeutic approach Positive diagnosis, simple explanation, reassurance, lifestyle and dietary advice are the cornerstones of management. Refer all patients to www.theguttrust.org for information and online self-help. 6. Recommendations for symptomatic treatment - use standard drug doses in the BNF unless specified below reassurance & explanation diet and lifestyle changes 5 magnesium hydroxide drugs diet step 1 step 2 step 3 pain bloating diarrhoea constipation antispasmodic(s) tricyclic SSRI trial of probiotics loperamide codeine phosphate cholestyramine fybogel lactose exclusion slowly  wheat fibre intake up to 30g/day  wheat fibre and  soluble fibre intake  fibre intake to 10g/day  intake of fibre and gassy foods symptomatic treatment 6 review response movicol All of the antispasmodics can be tried, combining an anticholinergic + smooth muscle relaxant if necessary. Best used PRN as efficacy may wear off when used regularly Use loperamide daily at the lowest dose required - using the liquid preparation makes it easier titrate a low dose to avoid constipation. Loperamide increases anal tone and has no CNS effects unlike codeine which causes dependence and should be avoided longterm. Cholestyramine is useful for bile salt malabsorption but needs slow and careful titration. Osmotic laxatives are best taken in small regular doses. They do not damage the bowel and longterm use is acceptable. Start tricyclics at low doses (5-10mg) nocte and increase in weekly increments of 10mg up to 30mg. Initial side-effects such as dry mouth, nausea, constipation and sedation usually settle so encourage patients to persist with the drug if they occur. Nortriptyline is the best tolerated. SSRI’s are less effective for IBS but may be better in depressed patients and do not cause constipation. They can be used alone or in combination with a tricyclic. Continue for at least 12 months before weaning off. new alarm features since initial presentation good response to treatment in guidelines abnormal inflammatory markers or TTG refractory to all treatments including antidepressants urgent referral according to guidelines observe in primary care referral to gastroenterology outpatient clinic or direct access OGD with duodenal biopsy

Anti-spasmodics dicycloverine hyoscine anti-cholinergics mebeverine alverine colpermin anti-cholinergics smooth muscle relaxants improve global symptoms (NNT 5.5) relieve pain (NNT 8.3) try them all – can be used in combination can be used PRN often given before food

Anti-diarrhoeals loperamide best used regularly titrate lowest dose that slows the gut no effect on abdominal pain improves anal tone non-addictive safe for longterm use codeine phosphate cholestyramine

Laxatives soluble fibre fybogel osmotic laxatives magnesium hydroxide movicol no evidence of longterm gut damage best used regularly at a low dose lactulose – wind and bloating senna – abdominal cramps

Tricyclic drugs most effective agents for pain in IBS (NNT 5) affect motility, visceral sensitivity and central processing may alter pain perception during acute stress need to sell them – resistance common start at low dose 5-10mg and titrate slowly taper after 6-12 months adverse effects in 1 in 3 patients (NNH 22) help with sleep nortriptyline has fewer side-effects

Serotonin re-uptake inhibitors Rx anxiety, depression & somatisation serotonin modulates gut sensory & motor function Creed 2003 n = 257 randomised placebo-c paroxetine 12 weeks global improvement health related QoL p<0.001 Kuiken 2003 n = 40 fluoxetine 6 weeks abdominal pain NS Tabas 2004 n = 110 p<0.01 Tack 2006 n = 23 crossover placebo -c citalopram pain bloating impact of symptoms on QoL overall wellbeing p<0.05

CBT in addition to antispasmodics for IBS in primary care: randomised controlled trial IBS patients aged 17-54 in primary care nurse delivered CBT (6 sessions) + mebeverine (n=72) controls on mebeverine alone (n=77) follow up at 3, 6 and 12 months using IBS-SSS symptom benefit at 3 months waned at 6, 12 months improved coping behaviours up to 6 months less effective in males who believed in a physical cause treatment and social costs not reduced Kennedy et al Health Technol Assess, Jun 2006

Gut-directed hypnotherapy for IBS: piloting a primary care based RCT IBS patients aged 18-65 failing standard Rx intervention (n=41): gut-directed hypnotherapy (5 sessions) + usual management controls (n=40): usual management reduced symptom scores at 3 months less likely to require medication no effect on QoL Roberts et al Br J General Practice, Feb 2006