Peer reply DB 9

1-Mercedez:

According to statistics from the International Foundation for Gastrointestinal Disorders (IFFGD), irritable bowel syndrome (IBS) is the most common GI disorder with an international prevalence rate of approximately 10-15% (2016). In the United States alone, there are 2.4 and 3.5 million of annual visits to the physician reported (IFFGD, 2016). Between 35 to 40% of those who report IBS are male and 60 to 65% are female. There is high cost to society related with IBS of approximately $21 billion dollars, which represents direct medical care and indirect loss related to work absences and poor productivity (IFFGD, 2016).

The goal of treatment for Jordan is to improve and relief her symptoms in order to prevent worsening of symptoms.

According to IFFGD (2016), the first line of treatment for IBS is to implement lifestyle changes in the patient that may be associated with symptoms. Examples of these changes include dietary modifications. It is important to avoid food that is gas-forming and high in fermentable oligosaccharides, disaccharides, monosaccharides and polyols. Also, water-soluble fiber (e.g. psyllium) has a high water-holding/gel-forming capacity that is preserved throughout the large bowel, and can act as a bulking agent to firm loose/liquid stools in patients with diarrhea (Moayyedi et al., 2017). It is also important to remind our patients that increased stress may result on worsening of IBS symptoms.

Drug therapy recommended should gear towards the patient’s predominant symptoms. For example, antidiarrheal agents such as loperamide will act on opioid receptors and will slow down peristalsis (Schmick and Hornecker, 2017). Because of its availability over the counter, established effect on diarrhea and relatively low cost, loperamide is frequently used as a first-line therapy for IBS-D. Loperamide may also be used prophylactically when a patient anticipates episodes of diarrhea. Adverse effects of loperamide include abdominal cramps, constipation, bloating and nausea (Moayyedi et al., 2017).

Bile salt sequestrants, such as cholestyramine or colesevelam, may be effective against diarrheal symptoms in some patients with IBS. It is suggested that bile acid sequestrants should be considered after other therapies targeting diarrhea have been unsuccessful (Moayyedi et al., 2017).

Recent evidence and studies suggests a role of antibiotics in the treatment of IBS. Small intestinal bacterial overgrowth has also been connected with IBS in general, particularly those exhibiting diarrhea. Rifaximin is an oral, minimally absorbed, broad-spectrum antimicrobial agent that targets the GI tract. Some studies have shown that two weeks of rifaximin treatment provided adequate relief of global IBS symptoms and individual symptoms of loose stools, abdominal pain, and bloating (Moayyedi et al., 2017).

Antidepressants and antispasmodics are also use in IBS. Tricyclic antidepressants (TCAs) are used but studies on its used are limited. Because of it, and the potential adverse effects of TCAs, dosages prescribed are lower than when used to treat depression or anxiety (Moayyedi et al., 2017).

2- Rosquete:

Jordan is a 35-year-old woman who presents with intermittent diarrhea with cramping that is relieved by defecation. The diarrhea is not bloody or accompanied by nausea and vomiting. Review of past medical history includes some childhood “stomach issues”, HTN, and a recent cholecystectomy. She works in the environmental department of a large hotel. She denies alcohol and cigarette.

Diagnosis: Irritable Bowel Syndrome (IBS)

Discuss the epidemiology of IBS?

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal (GI) disorder with worldwide prevalence rates ranging generally in the area of 10–15%. Functional disorders are conditions where there is an absence of structural or biochemical abnormalities on common diagnostic tests, which could explain symptoms. Among patients about 40% of people have mild IBS, 35% moderate IBS, and 25% severe IBS. Many people don't recognize IBS symptoms, and it is one of the most common disorders seen by physicians. IBS is the most common disorder diagnosed by gastroenterologists and accounts for up to 12% of total visits to primary care providers.

What is your treatment goals for this patient?

The goal of treatment isn't just to ease bowel problems. It should also soothe the stomachaches, pain, and bloating that often come with IBC. The goals are symptom relief and improved quality of life. Also exercise, antibiotics, antispasmodics, peppermint oil, and probiotics appear to improve symptoms. Over-the-counter laxatives and antidiarrheals may improve stool frequency but not pain.

Discuss First line and second line drug therapy for IBS. Please include pharmacotherapeutic information.

Modification of dietary habits should also be a first-line consideration. Avoidance of foods that are gas-producing and high in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols and that have a history of aggravating symptoms may provide benefit. The initial treatment approach for IBS should involve nonpharmacologic management and then focus on drug therapy for the individual patient’s predominant symptoms according to the limited evidence-based medicine supporting specific agents in the treatment of IBS symptomatology. The monitoring, education, and support of patients that pharmacists provide renders their role vital in IBS management. Although all patients with IBS have symptoms of abdominal pain and disordered defecation, treatment needs to be individualized and should focus on the predominant symptom. Abdominal pain, bloating, constipation and diarrhea are the four main symptoms that can be addressed using a combination of dietary interventions and medications. Treatment options include probiotics, antibiotics, tricyclic antidepressants, selective serotonin reuptake inhibitors and agents that modulate chloride channels and serotonin.

Smooth muscle relaxants: These are best for relieving or preventing intestinal cramping.

Antidiarrheal medications: Medications for those with diarrhea slow intestinal transit and reduce the frequency of bowel movements while improving the consistency of the stool.

Laxatives: For patients who have constipation as the predominant symptom.

Antibiotics: To attempt to alter the composition of the gut flora that might be responsible for the fermentation of poorly digested carbohydrates.

Low-dose antidepressants: If pain and diarrhea are your predominant symptoms, you may find relief with these medications that work on the gut’s nervous system to make it less reactive to foods you eat or to emotional stress.

References

Chaudhary NA, Truelove SC. The irritable colon syndrome. A study of the clinical features, predisposing causes, and prognosis in 130 cases. Q J Med. 1962; 31:307–322.

Kruse FH. Functional disorders of the colon: the spastic colon, the irritable colon, and mucous colitis. Cal West Med. 1933;39(2):97–103.

Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–1491.