Management

Nature's Quick Constipation Cure

Constipation Help Relief In Minutes

Get Instant Access

As previously mentioned, a large number of patients with symptoms of IBS do not report these symptoms to their physicians. Moreover, some symptomatic patients who visit a physician do not require specific therapy but rather derive a great deal of benefit from explanation of their diagnoses and factors that worsen IBS, including stress and possibly dietary factors. A stepwise approach, beginning with the establishment of a trusting physician-patient relationship is required for effective management of IBS.3 A summary of this approach is shown in Table 6.3.

The health care provider should reassure patients with IBS that their condition will not degenerate into other life-threatening disorders, that it most likely represents a physiologic abnormality involving the intestinal motor and sensory system, and that IBS can correlate with psychosocial disorders that require treatment when present. At this point, determining the severity of the condition may help with planning future therapeutic regimens. For example, the majority of patients with severe excruciating abdominal pain and symptoms that adversely affect the overall quality of life should be investigated for a history of physical or sexual abuse or the presence of the aforementioned psychiatric disorders.4 Early involvement in psychological or psychiatric care may be highly beneficial in these patients. If a physiologic disturbance of the gastrointestinal tract appears to predominate, utilization of pharmacotherapy is justified and may be highly beneficial.

After the diagnosis of IBS has been made, symptomatic improvement may be achieved using dietary modification. One study has shown that 48% of patients with IBS benefit from the elimination diet, with the gradual reintroduction of foods that do not cause additional symptoms.30

Table 6.3. Stepwise approach for the treatment of patients with IBS

Establish physician-patient relationship Reassurance Education Lifestyle modifications Stress management Dietary changes Healthy habits, exercise Pharmacotherapy Psychological/behavioral therapy

Elimination of lactose is recommended, as up to 60% of the population in the United States has lactose intolerance and these symptoms can mimic IBS.31 Both caffeinated and decaffeinated coffee have been demonstrated to stimulate motor activity of the rectosigmoid colon in normal volunteers.32 Sorbitol, a sugar alcohol that is a common ingredient of sugar-free candies, medicines, and antacids, may produce bloating, diarrhea, and gas, mimicking IBS. Establishment of exercise and stress management routines is often also recommended. A method for determining whether life stresses, dietary components, and other psychosocial factors exacerbate IBS symptoms involves the use of a symptom diary for 2 to 6 weeks. This may be used to determine if dietary factors and stressful events are associated with worsening of IBS symptoms. These journal entries may then be used for recommending dietary exclusions, stress management, and psychological counseling.2,3

Additional therapy for IBS is warranted when patients and their physicians have determined that the condition has adversely affected the patient's quality of life. Initial treatment for patients with constipation-predominant IBS usually involves increasing dietary fiber intake and the addition of commercial bulking agents. Fiber decreases total gut transit time and may lessen colonic contractility.33 Fiber supplementation has been demonstrated to be beneficial in several studies of patients with constipation-predominant IBS.3 A variety of fiber supplements are available commercially and include synthetic fibers containing calcium polycarbophil (Fibercon® Wyeth Pharmaceuticals,Madison,NJ; Equalactin Newmark Laboratories, Edison, NJ). Soluble fibers occur naturally in a number of fruits and grains, including apples, oranges, apricots, prunes, and oat bran. Psyllium, the active component in Metamucil® and Konsyl® (Proctor and Gamble, Mason, OH) is also a soluble fiber. Methylcellulose, the active ingredient of Citru-cel®, is an insoluble fiber that theoretically may produce less gas and bloating than soluble fibers in some patients. Over-the-counter laxatives may help some patients with constipation-predominant IBS. Osmotic laxatives, including milk of magnesia and mineral oil, and stool softeners such as docusate sodium, may be safely and effectively administered in some patients. Polyethylene glycol in a balanced electrolyte solution (MiralaxTM, Braintree Laboratories, Braintree, MA) is a prescription medication that

Figure 6.2. Subject Global Assessment of Relief. The data demonstrate the weekly percent of study patients who had complete or considerable relief or were somewhat relieved with tegaserod 6mg b.i.d. and placebo. *p < .05, **p < .01 vs. placebo (39). Ehrenpreis ED, Burns EA, Hoffman C. The AFP guide to diagnosis and treatment of the irritable bowel syndrome. Copyrighted and published by Family Practice Education Network, Illinois Academy of Family Physicians, Lisle, Illinois, 2003.

Figure 6.2. Subject Global Assessment of Relief. The data demonstrate the weekly percent of study patients who had complete or considerable relief or were somewhat relieved with tegaserod 6mg b.i.d. and placebo. *p < .05, **p < .01 vs. placebo (39). Ehrenpreis ED, Burns EA, Hoffman C. The AFP guide to diagnosis and treatment of the irritable bowel syndrome. Copyrighted and published by Family Practice Education Network, Illinois Academy of Family Physicians, Lisle, Illinois, 2003.

is very similar to a colonoscopy preparation solution. This is administered as a 16-g dose in 8 oz of fluid once or twice a day. This agent has proven to be effective in patients with refractory constipation.34 Furthermore, antispasmodic therapy including anticholinergic agents may be beneficial for pain relief.3 Due to the fact that these are constipating agents, antispasmodics have a more limited role in constipation-predominant IBS. Antidepressants have been utilized for the treatment of IBS and other functional bowel disorders, and their effectiveness appears to occur primarily due to central nervous system activity.3,33 Tricyclic antidepressants, which have anticholinergic properties, have been demonstrated to improve abdominal pain and diarrhea in patients with IBS.4 These drugs often produce constipation and should be used carefully in patients with constipation -predominant IBS. Selective serotonin reuptake inhibitors (SSRIs) may cause either diarrhea or constipation and have been utilized as clinical treatment for IBS and other functional bowel disorders. Evidence-based studies proving the beneficial effects of most of these treatments of IBS are lacking at this time.

Recently, the 5-HT4 receptor agonist tegaserod (Zelnorm®; Novartis Pharmaceuticals, East Hanover, NJ) has been approved by the Food and Drug Administration (FDA) for the treatment of constipation-predominant IBS. This drug, which binds the 5-HT4 receptors in the gastrointestinal tract with high efficiency, has been shown in laboratory studies to stimulate intestinal peristalsis and secretion and to reduce visceral sensitivity.35 Tegaserod also stimulates the release of other neurotransmitters including calcitonin gene-related peptide, which may contribute to its effects on gastrointestinal function.35,36 Physiologic studies have demonstrated that tegaserod enhances basal motor activity and corrects intestinal motility in patients with constipation-predominant IBS. Three randomized, placebo-controlled doubleblind clinical trials involving 2471 female patients with constipation-predominant IBS who ingested either tegaserod (6mg b.i.d.) or placebo for 12 weeks were performed prior to approval of this drug.3,4 These studies demonstrated that tegaserod therapy results in the overall relief of discomfort and other symptomatology in female patients with constipation-predominant IBS (Fig. 6.2).37 Additionally, patients on tegaserod experienced more frequent bowel movements, decreased abdominal pain, and improvement in stool consistency.3,4,37 The most common self-limiting adverse reaction experienced in subjects consuming tegaserod was diarrhea. Future therapies for constipation-predominant IBS include the development of additional 5-HT4 agonists such as prucalopride and renzapride.38 Other gut-directed therapies being investigated for IBS include 5-HT1 receptor agonists, kappa opioid receptor agonists, somatostatin analogues, as well as antagonists of neurokinin and tachykinin.39

Was this article helpful?

0 0
Eliminating Stress and Anxiety From Your Life

Eliminating Stress and Anxiety From Your Life

It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.

Get My Free Ebook


Post a comment