Patient Centered vs. Evidence Based Care in IBS Treatment

For this early-morning presentation, Lin Chang, MD first looked at patient-related factors that guide IBS management: it’s a multidimensional disorder with a heterogeneous patient population (multiple symptoms, complex pathophysiologic mechanisms, varying treatment responses) that requires the gastroenterologist to look at individual patient characteristics—including illness severity, most bothersome symptoms, factors that are most relevant to the patient, and the most appropriate treatment—and follow a holistic and integrated approach.

According to Lang, when treating patients with mild symptoms, gastroenterologists should look at the patient’s diet, provide lifestyle advice, achieve a positive diagnosis, explain the situation to the patient, and reassure them that you’re there to help them get better. For patients with moderate symptoms, the physician should perform the following as well as provide a follow-up visit, manage stress, and look at pharmacotherapy. For patients with severe symptoms, the physician should look at psychological treatments, provide continuing care, and work to improve functioning. Lang notes that the goal shouldn't necessarily be to remove symptoms, but to improve the patient’s ability to manage these symptoms and cope.

Lang next discussed the methods for establish a good rapport with a patient:

• Listen actively
• Validate the patient’s feelings
• Provide empathy
• Identify the agenda
• Don’t overreact
• Educate
• Reassure
• Set realistic and shared goals
• Negotiate
• Help the patient take responsibility
• Establish limits
• Maintain continuity

The speaker also noted, referencing a recent study, that the more a gastroenterologist follows the treatment guidelines for IBS, the less patients need to visit the physician’s office. “So what do patients want?” she asked. They want their physician to provide comprehensive information, tell them where to get information on IBS, answer questions during an office visit and also via the phone or e-mail, and listen to them.

Lang next discussed the ACG Task Force that looked at the management of IBS with constipation (IBS-C), particularly the use of psyllium hydrophilic mucilloid, wheat bran, polyethylene glycol, and lubiprostone 8micrograms twice daily.

The efficacy of fiber in IBS was given a grade 2C, based on the results of six studies looking at 321 patients, which showed fiber to have a significant effect on overall IBS symptoms. However, Lang says bran has not been shown to be effective in IBS. She does say to use it in mild-moderate IBS, noting that it is more effective in IBS with constipation. “You may need to start with a lower dose and increase as needed and as tolerated,” she explains, “because high-fiber foods often cause gas and cramping… Assess where the fiber in your patient’s diet is coming from.”

The ACG Task Force stated that psyllium is moderately effective for IBS, giving it a grade 2C. Lang echoes that, saying it is more beneficial than bran or placebo, but that the effects of all three seem to equal out over time.

Looking at laxatives in IBS, the task force gave polyethylene glycol a grade 2C, as it improved stool frequency but not abdominal pain in one small study in adolescents with IBS-C. No studies have been conducted looking at bisacodyl in IBS-C, but a randomized, two-week trial looking at 10mg/day saw the agent increase complete spontaneous bowel movement from 1.1 to 5.2 vs. 1.1 to 1.9 for placebo. According to Lang, “laxatives can help constipation symptoms, but may only partially help bloating and pain/discomfort. Titrate them as needed, and avoid overuse by patients, because they can worsen symptoms. Laxatives give patients the feeling they have to evacuate” even if they’ve already done so.

The ACG Task Force gave lubiprostone at grade 1B in IBS-C, as patients taking the agent showed a significantly higher overall response versus placebo. Lang says to start at 8 micrograms twice daily, increasing to 24 micrograms twice daily if needed, with the agent taken with meals.

The presented switched gears, next discussing the results of the ACG Task Force that looked at the management of IBS with diarrhea (IBS-D). The task force looked specifically at antispasmodics, hyoscine, cimetropium, pinaverium, peppermint oil, and alosetron.

For patients with IBS-D, loperamide is effective for treatment of diarrhea, reducing stool frequency and improving stool consistency. However, the agent is no more effective than placebo at reducing pain, bloating, or global symptoms of IBS. Lang says to use it as needed for episodic diarrhea, using it proactively and starting at a low dose to avoid constipation and going up to two tablets qid.

The task force gave alosetron a grade 2B for males and 2A for females, based on eight studies looking at just under 5,000 patients. “Alosetron is indicated for women with severe IBS-D and has been on a restricted use program” because of side effects, says Lang. She says to start with 0.5mg bid, teach the patient to titrate the dose to avoid constipation and relieve pain and diarrhea. Also, monitor symptoms for constipation and ischemic colitis.

Antispasmodics were given a grade 2B-C for IBS based on 22 studies looking at 12 drugs in 1,778 patients. Lang says to use them in patients with intermittent symptoms—chronic use can cause constipation and dry mouth—to help decrease post-prandial pain. Advise patients to take them 30 minutes before a meal.

Lang finished up her presentation with a look at behavioral and psychological treatment in IBS, explaining that such treatment should be considered particularly if a patient has poor coping skills or psychological symptoms. Gauge the patient’s interest and motivation in such treatment, she advises, explaining that it might be best to just provide in the information to someone who seems less interested, as many patients go home, think about the information, and then come back with a desire to look into it further. Use cognitive behavioral therapy for poor coping and psychotherapy when a stressful relationship is associated with IBS symptoms, she notes, adding that hypnosis can be helpful but that you’ll need to find therapist with IBS knowledge.

In providing a summary of the general treatment approach, Lang says to first assess particular symptoms that need to be treated, including IBS symptoms (pain, diarrhea, etc), non-GI symptoms (eg, poor sleep), and co-morbid conditions (eg, anxiety, depression, fibromyalgia). Also, look at the side effect profiles and cost of available medications, taking into consideration the patient’s previous medication experiences and preferences.