American College of Physicians: Internal Medicine — Doctors for Adults ®


Work up the whole patient when treating IBS

From the November ACP Internist, copyright 2009 by the American College of Physicians

By Paula S. Katz

Before pulling out your prescription pad, experts say, the best way to treat a patient with irritable bowel syndrome (IBS) is to first view him or her as a whole person.

“What’s driving the symptoms in a patient more, the brain or the gut?” asked Lin Chang, MD, professor of medicine in the division of digestive diseases at the David Geffen School of Medicine at the University of California, Los Angeles. Once you have considered this, you can determine which treatment interventions can help relieve symptoms and improve functioning, she said.

Because IBS patients are such a heterogeneous population, treatment plans are going to vary. “I don’t think there’s going to be one therapy for all IBS patients,” Dr. Chang said.

Management of IBS can be quite challenging and complicated. There’s new research about drugs, but also concerns about the risk-benefit ratio of pharmacotherapy. The pathophysiology of the disease is better understood but knowledge is still incomplete, Dr. Chang said. Moreover, physicians may achieve some good results using alternative medicine and psychotherapy for certain IBS patients. Dr. Chang and other experts addressed the issue at Digestive Disease Week in Chicago earlier this year.

First steps

To meet the challenge of managing IBS patients, physicians’ most important intervention has nothing to do with pharmacology.

“Before prescribing a pill for IBS, the most important intervention is to take time to listen to the patient,” said Philip S. Schoenfeld, MD, associate professor of medicine at University of Michigan School of Medicine, Ann Arbor, Mich.

Only then should you explain a little of the pathophysiology of IBS so the patient “knows you do not think that true abnormalities are occurring in the GI tract and these symptoms are not ‘in her head’,” he said. Next, set appropriate expectations. “You’re unlikely to cure the disease, but you can minimize the frequency and severity of IBS symptoms with treatment. Establishing an effective patient-physician relationship will be crucial to maximizing response to therapy,” he explained.

Dr. Chang acknowledges to patients that while it would be nice to have medications that treat all their symptoms, this is often not the case. She explains that what is available now is the best they have. Then she focuses the treatment plan by asking patients, “What’s your most bothersome symptom?”

Drug therapy

Drugs often still play a part in treating IBS symptoms. In reviewing new drug therapy research for IBS, Dr. Schoenfeld said some studies show selective serotonin reuptake inhibitors (e.g., citalopram) and tricyclic antidepressants (e.g., nortriptyline at low doses before bed) are more likely to improve IBS symptoms, particularly abdominal pain, relative to placebos. He also said data show the following:

  • Lubiprostone. Randomized, controlled trials clearly demonstrate that lubiprostone (Amitiza) at a dose of 8 µg twice daily improves overall IBS symptoms better than placebo in certain patients with IBS and constipation (e.g., women and those younger than 65 years old). Patients should be told that the drug should be taken with food during the first week to reduce nausea, a known early side effect.
  • Osmotic laxatives. There are no randomized, controlled trials on the efficacy of osmotic laxatives for treatment of constipation-predominant IBS. “I think [they work] great for constipation, but it is not clear if osmotic laxatives will improve the abdominal discomfort and bloating of IBS,” Dr. Schoenfeld said.
  • Rifaximin. Rifaximin (Xifaxan) is more effective than placebo for global improvement of IBS and for bloating in patients with diarrhea-predominant IBS. Dr. Schoenfeld noted that there are no data to support long-term safety and effectiveness of non-absorbable antibiotics, but that for these drugs to work for IBS, patients need to take at least 400 mg three times a day for at least 10 to 14 days. While one study showed sustained improvement for 10 weeks, further research needs to find out how much longer the patient can remain symptom free and which patients are most likely to respond to this treatment.
  • Bifidobacterium infantis 35624. He said experience with his own patients suggests that it works best for bloating and pain in mild to moderate IBS.

Antidepressants work, Dr. Schoenfeld said, but patients often don’t see how they relate to IBS. So instead of just writing a prescription for antidepressants when he feels it’s necessary, Dr. Schoenfeld shows the patient an image of the body that clarifies a mind-gut connection. This helps validate the idea that there may be a defect in how the gut communicates with the brain. Then he says, “And here’s a medicine to modify how the brain receives [the gut’s message].” After that, he said the vast majority of his patients are willing to try medication.

Looking ahead, Dr. Chang said that drugs in development include asimadoline, a peripheral kappa-opioid agonist for diarrhea-predominant (IBS-D) and alternating (IBS-A) patients, and dextofisopam and crofelemer for IBS-D patients. Linaclotide (MD 1100) and DDP733 (pumosetrag) are being studied for IBS-C.

A possible injectible for IBS with pain is glucagon-like peptide-1 (GLP-1). Dr. Chang said drug development includes an ongoing identification of novel drug targets along the brain-gut axis. More information about drugs in development for IBS is online.

Alternative therapies

Use of alternative therapies is gaining momentum in IBS treatment. For example, Dr. Schoenfeld noted that peppermint oil “has pretty darn good data” showing 60% of patients’ symptoms are likely to improve compared with placebo. He noted that patients should be warned against biting the tablet. “It tastes horrible and gives incredible heartburn,” he said. He said to be cautious using hyoscine, an anti-spasmodic agent, which showed a decrease in pain frequency but was similar in effect to placebo or acetaminophen.

“The most important intervention is to take time to listen to the patient.”
—Philip S. Schoenfeld, MD

Dr. Chang has patients keep a daily diary for a couple of weeks to identify food triggers and other factors that may affect symptoms. Dietary restrictions can be helpful for some patients, though there is no “one size fits all” diet for IBS, said Kirsten Tillisch, MD, from the Center for Neurobiology of Stress at the David Geffen School of Medicine at the University of California, Los Angeles. She said that while strict elimination diets can help identify specific food triggers for some people, they are difficult to follow and should be used with the help of a nutritionist.

But physicians need to be aware that patients are going to health stores and picking up products claiming to address IBS or eliminate gluten. This puts the pressure on physicians to ask the right questions, Dr. Tillisch said.

Although she has seen patients do well with traditional Chinese medicine, she said physicians should be cautious about recommending it because there hasn’t been a lot of evidence supporting its therapeutic benefit, and the lack of regulation raises concerns about the quality of the herbs used.

Dr. Tillisch also noted that STW 5 (Iberogast), a combination extract of nine herbs taken as a liquid before meals, is an over-the-counter option for IBS. While it appears to be well tolerated and may be effective, she said overall evidence is insufficient and higher-quality trials are needed.

Non-drug treatments

Dr. Tillisch said that her practice sees mostly women who have tried and been disappointed by drug therapies. “I’m usually the third or fourth doctor they’ve seen,” she said. “Often they’ve had multiple procedures I wouldn’t have recommended.”

Non-drug treatments, such as relaxation, psychotherapy, hypnotherapy, and cognitive behavioral therapy (see sidebar), are important therapies that can help relieve symptoms and improve coping skills in IBS patients, Dr. Chang said. Dr. Tillisch said her patients have had good results with IBS hypnosis.

While some patients may balk at some of these options, Dr. Tillisch said developing a relationship with patients and finding out what they’re most comfortable with will open them up to the physicians’ suggestions, especially when it comes to psychological therapy. “They won’t say ‘yes’ to that necessarily the first time,” she said.

She reviews data with patients about how psychological therapy may benefit them and also discusses costs. She said it’s important to explain what she’s referring them for and offers to call to explain to the mental health specialist why she is making the referral, especially if it’s for a complicated patient. “For example, if I have a patient who has undergone multiple recent stressors that may be difficult for her to talk about but may be impacting her gastrointestinal symptoms, I can discuss those interactions with the therapist in advance so they don’t end up starting off on a different topic. It saves the psychologist time and gets the patient into treatment relevant to the medical condition faster,” she said.

It’s best to use psychiatrists, psychologists and other mental health professionals who know about IBS if possible. It’s also important for them to be willing to collaborate. “It’s not useful if they’re antagonistic to Western medicine so I refer only to those who will work with me to formulate a plan that is safe and useful to the patient,” Dr. Tillisch said.

In the end, it’s the collaboration that works, she said. “I defer to the psychologist to treat the underlying triggers that are driving the disorders when the drugs don’t work. Then I treat as needed,” she said.



Cognitive behavioral therapy guides the mind-gut connection

Cognitive behavioral therapy (CBT) is one way to address psychosocial factors, such as intense worry, that can aggravate symptoms of irritable bowel syndrome (IBS).

“Learning behavioral self-management strategies such as worry control strategies is better than going for a second round of tests when the medical problem is a benign condition like IBS,” said Jeffrey M. Lackner, PsyD, a clinical psychologist specializing in working with IBS patients and director of the Behavioral Medicine Clinic at the University at Buffalo in New York. “Patients can learn more effective stress management skills such as learning how to handle the unpleasantness of an uncontrollable problem versus solving or controlling problems that are beyond their control,” he said.

CBT is based on the premise that the way an individual thinks about an event, not the event itself, determines how he or she responds. Those thoughts and behaviors then become learned. CBT helps patients control their responses by identifying and then modifying them an “unlearning” process. It consists of:

  • patient education to not only enhance knowledge but reduce misconceptions,
  • self-monitoring to identify triggers and gain objectivity,
  • muscle relaxation exercises, such as diaphragmatic breathing and progressive muscle relaxation to prevent hyperarousal and help patients control confidence in their ability to regulate themselves,
  • cognitive restructuring to teach patients to identify and correct erroneous perceptions and help manage controllable versus uncontrollable stressors,
  • problem-solving training to identify and analyze the problem, come up with flexible solutions, choose one, implement it, then evaluate it and
  • relapse prevention by having patients monitor thoughts, physical reactions, and behavior.

Dr. Lackner said CBT can work for typical IBS patients, whom he described as problem-solvers, the ones always pitching in for the neighborhood barbecue or organizing the carpool to a kids’ event. These patients always want to solve or fix problems, which isn’t always possible.

He also recommended CBT for patients who:

  • prefer a non-drug option,
  • have persistent IBS without significant relief from first-line treatments,
  • have moderate to severe symptoms,
  • have an impaired quality of life,
  • display illness behaviors such as seeking reassurance or requesting testing or
  • have coexisting distress such as anxiety or depression.

One downside can be covering the cost of therapy, which can range from $100 to $200 per hour, said Kirsten Tillisch, MD, from the Center for Neurobiology of Stress at the David Geffen School of Medicine at the University of California, Los Angeles. And trying to find insurance coverage for CBT can cause even more stress for IBS patients.

“I emphasize that it’s not a lifetime of therapy and most of my patients have invested that money in other treatments anyway,” Dr. Tillisch said. “If money is really limited, I do my own version of CBT.”

The greatest challenge may be finding a psychologist who does CBT and knows about IBS. Dr. Lackner said the former may be more critical than the latter. “They should have a working knowledge of clinical gastroenterology,” he said. “It’s more important that they know the principles and techniques of CBT.”



Go online for more

More on irritable bowel syndrome is available online at PIER.


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