1. 1st draft IBS/IBD Cross CCG pathway
This based on the guidelines written Dr Bu’Hayee and NHS Greenwich CCG Medicines Management Team

2. Presenting with symptoms, but unknown IBD
IBS pathway 1:
Presenting with symptoms, but unknown IBD
Patient presenting with lower gastrointestinal symptoms for at least 6 months suggestive of irritable bowel syndrome (IBS) WITHOUT ALARM SYMPTOMS: • Abdominal pain (relieved by defaecation, made worse by eating IBS-A) • Bloating (IBS-B) • Constipation (IBS-C) altered bowel frequency or stool form • Diarrhoea (IBS-D) is common; overlap exists (IBS-M– mixed)
Suggest Advice & Guidance for:-
1. Equivocal FCALP results, these can be monitored over a
longer period every 4-6w.
2. Patients with –Ve FOBT rarely require further investigations
3. Patients with simple dyspepsia <55, that are non-responsive
to ppI can be classified as IBS-A,
FBC, ESR, Calprotectin
Coeliac screen, TFTs, (stool MCS)
Raised CRP, ESR and/or FCALP >150
Bloods normal and/or FCALP <60
Bloods normal and/or FCALP
RED FLAGS
Unintentional weight loss
New IDA
Persistent rectal bleeding/bloody diarrhoea that does no resolve.
A family history of bowel or ovarian cancer
> 60 years of age, a change in bowel habit lasting more than 6 weeks with looser and/more frequent stools
+Ve Coeliac Screen
Repeat FCALP in 4 weeks from first test; Consider IBS advice in meantime
(with proviso of re-test)
IBS pathway
Primary care
Increasing concern, struggling with
symptoms suggest refer on.
Consider C+B referral, avoid advising dietary restrictions
Consider 2WW/Urgent Referral to GI/Colo-rectal
Refer for ‘new IBD’ OPA via fax/hotline (to be seen <2-6/52)
Secondary care

3. IBS pathway 2:
Treatment options
This only applies to patients that IBD or other significant pathology has been excluded via IBS initial algorithm
Key symptom
Constipation predominant symptoms
Trail Ispaghula and Macrogol for 3/12 each
All treatment options are based on recommendations of NICE CG61 IBS 2015.
Bloating, pain, diarrhoea
Encourage a frequent bowel habit, as this will help decrease symptoms
Offer verbal and written lifestyle and physical activity advice, see next page.
Community dietics referral for FODMAPS
Mebeverine 135mg tablets 1-2 three times a day
Loperamide 2mg capsules 2-4 caps twice a day max 16 mg daily
If pain and IBS-C consider guanylate cyclase-C receptor agonist Linaclotide 290 micrograms once daily for 6 weeks, can be initiated be Primary and Secondary
Primary care
Referral to Gastroenterology for second line treatments
Pain/Diarrhoea based Constipation/Bloating
Amitriptyline 10mg-30mg at night
Secondary care
Nortriptyline 2.5mg-10mg at night
Fluoxetine 20mg once daily
Citalopram 10mg to 20mg once daily

4. Dietary/Lifestyle Sheet
Have regular meals and take time to eat.
Avoid missing meals or leaving long gaps between eating.
Drink at least eight cups of fluid per day, especially water or other non-caffeinated drinks, for example herbal teas.
Restrict tea and coffee to three cups per day.
Reduce intake of alcohol and fizzy drinks.
It may be helpful to limit intake of high-fibre food (such as wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice); REDUCE INSOLUBLE FIBRE.
Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods.
Limit fresh fruit to three portions per day (a portion should be approximately 80 g).
People with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.
People with wind and bloating may find it helpful to eat oats (such as oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day); INCREASE SOLUBLE FIBRE.
Some people find taking probiotics regularly helps relieve the symptoms of IBS. However, there is no scientific evidence to prove that probiotics work and have beneficial health effects. If you decide to try probiotics, make sure you follow the manufacturer's instructions and recommendations regarding dosage, you should continue for at least 4 weeks to notice any difference. This is not available on prescription.
Some people claim therapies such as acupuncture and reflexology can help people with IBS.

5. Coeliac Pathway: Patient declines Fatty Liver Repeat LFTs every 24/12
Not anaemic, raised LFTs, +VE TTG
Isolated GGT – reassure no further action
+Ve Coeliac Screen, but not diagnosed
High GGT, ALT
Organize US
Offer direct access OGD
Patient declines
Fatty Liver
Organise C+B appt approx 4/52 post OGD date
Check AST, plts, alb. Calculate NAAFLD Score at
Repeat LFTs every 24/12
Stable in community, advise regular vaccinations, good compliance with GFD
Primary care
Score over -1.45
Maximise cardiovascular risk/diabetes lifestyle factors
See in clinic organise, explain diagnosis, organise DEXA and dietics RV
Organize C+B appt
Secondary care
Dietics; Stable weight and dexa over 18/12
Suggest Urgent to routine referral dependant on US findings

6. IBD pathway 1: ULCERATIVE COLITIS Mesalazine (5asa) pathway
Patient with known UC with flare of symptoms
Taking mesalazine only
CHECK / ENCOURAGE ADHERENCE
- Typically 55% are adherent -
Newly diagnosed patient
Patients with Colonic Crohn’s disease may be treated on this pathway.
MAY NEED DISEASE-MODIFYING THERAPY
EG. AZATHIOPRINE NO
YES
≥ 2 flares in last 6/12?
Severity of this flare?
Consider minimising tablet
burden with high strength
formulations if not already
MILD
BO 1-3x per day +/- blood
No systemic symptoms
MODERATE
BO 4-6x per day with blood
No systemic symptoms
SEVERE
BO >6 per day with blood
Fever, tachycardia, hypotension
On rectal 5asa therapy alone (enema or supps)
On zero or maintenance dose
(2.4g Mesalamine, 1.5g Salofalk, 2g Pentasa)
CONTACT SECONDARY CARE
AT ANY STAGE IN THIS PATHWAY
Add oral 5asa at maximum dose and strength
Increase to maximum dose 5asa; Consider adding rectal therapy
On maximum dose
(4.8g Mesalmaine, 3g Salofalk, 4g Pentasa)
Primary or secondary care
2/52 review if Rx changed. Symptoms controlled?
YES
Prescribe prednisolone 40mg OD reducing by 5mg per week to zero with Ca+vitD suppl OD
Continue maximal therapy for 4/52 then reduce to maintenance unless evidence of disease activity NO
Advice from IBD helpine and/or refer for urgent OPA via helpline(<2/52)
Call Gastro SpR on-call
Admit via Medical team
Seen by IBD Cons within 48h
Secondary care

7. IBD pathway 2: IMMUNOSUPPRESSANT progression to BIOLOGIC THERAPY
Start point 1
Start point 2
Patient requiring therapy despite pathway 2
INFLIXIMAB
Rescue, initial funding request for 12/12
Hospitalised patient
VACCINATION AND VIRAL SCREEN
Should be performed at this stage
Start AZA
based on TPMT result
“Acute severe” UC
In-hospital response?
YES
High risk IBD?
Steroid dependency NO
?Surgery NO
INITIAL AZA MONITORING
Fortnightly FBC for 3/12, then every 3/12 there after
TGN level at least at 12/52
Recheck if failing therapy
AZA monotherapy
Biologic
Pathway (#3)
YES
Response
at 12 weeks?
YES NO
CI to biologic? NO
Alternative immunomodulator?
TACROLIMUS/MTX
YES
Remission for biologic cessation is defined as asymptomatic and biochemical and/or endoscopic and/or radiologic evidence of healing
YES
Response at 12 weeks? NO
Virtual / telephone/ nurse-led F2F follow-up
High risk or Complex IBD
Young patients (<40 years); Fulminant disease
Previous surgery for Crohn’s disease / early recurrence
Fistulising/penetrating Crohn’s disease at presentation
Unable to use steroids as bridge to immunosuppression
Already on immunosuppression (and adequate dosing)
Shared care can only start after 4/12 and only if patient stable
Secondary care
Offer of
shared care
Primary care

8. Switch biologic, and consider combination
IBD pathway 3: BIOLOGIC THERAPY, links for pathway IBD 2 UC CD
The most appropriate and cost-effective anti-TNF will be selected according to NICE guidance for CD
Expect 20% of local population of CD in this arm
The proportion of patients will be higher in tertiary care (population outside LSLBGB)
aTNF
Anti -integrin
2nd line
only
60%
40%
These figures are for new starters only.
Switching of stable patients is clinically inappropriate
OPD should offered subcut anti-TNF or Vedo as first line,
Hospitalized IV aTNFs.
ADALIMUMAB
INFLIXIMAB
VEDOLIZUMAB
Response at
12-16 weeks?
Dose optimisation or drug-switching must be discussed in IBD MDM
Reassessment may be at 4-8 weeks after change, dependent on dosing frequency
This cyclical section of the pathway can be repeated TWICE.
Remission for acute severe UC defined by
Mayo <2 when steroid-free
YES
Remission for biologic cessation is defined as asymptomatic and biochemical and/or endoscopic and/or radiologic evidence of healing NO
Possible to dose-optimise based on drug/Ab level?
YES NO
?Surgery
Switch biologic, and consider combination
On AZA? Need to optimize
Suitable for clinical trial? NO NO
Consider stopping
biologic therapy
YES
Remission at
12 months? NO
Possible to dose-optimise based on drug/Ab level?
Secondary care