INDIANAPOLIS, June 26 -- Although the recent withdrawal of tegaserod from the market has left a hole in the options available to treat irritable bowel syndrome (IBS), there are still many available.
So said Julia Pallentino, M.S.N, J.D., ARNP-BC, of the Medical Group of North Florida in Tallahassee, at the American Academy of Nurse Practitioners meeting here.
Education, reassurance, and medication are the key elements in treating irritable bowel syndrome (IBS), she told attendees.
Action Points
- Explain to interested patients that there is a link between the symptoms of irritable bowel syndrome and stress.
"Reassurance is reinforcing the fact that IBS is a real condition and not just in the patient's head," she said. "And it's telling patients that there are treatments available to alleviate the discomfort they feel."
The second component, education, includes clearing up any confusion patients have about their actual diagnosis. Many do not know that IBS, spastic colon, and functional bowel are all names for the same condition.
Teaching should reinforce that discomfort is caused by psychological alterations and that there is a link between symptoms and stress.
Medications traditionally treat the symptoms. The drugs that will be useful in treating a particular patient will depend on the symptoms the patient has.
"Final treatment options will largely be arrived at by trial and error," said Pallentino. "We try something and see if it helps, if not try something else."
Drug regimens for abdominal pain would include antispasmodic medications such as dicyclomine or Donnatal. They work to prevent spasms in the muscles of the gut by relaxing them, and also reduce the amount of stomach acid produced.
Tricyclic antidepressants in low dose may help reduce pain. Pallentino said she usually suggests amitriptyline 50 mg at bedtime. However, tricyclics should not be used in most cases when the patient is constipated; their anticholinergic properties slow the gut down.
When bloating and distention is the concern, antispasmodics are often useful. Over the counter antiflatulents such as Beano or Gas-X may help. Pallentino also said she's found that capsules of activated charcoal sold over-the-counter have been useful.
Digestive enzymes can help relieve this symptom, too. Pancreatic enzymes are available by prescription or through health food stores.
In some cases, antibiotics may lessen the bloating and distention caused by bacterial overgrowth. Among the antibiotics typically suggested for IBS are tetracycline and neomycin.
Constipation in IBS can respond to increased intake of fiber and fluids, along with exercise, Pallentino said. Laxatives may also be used.
Although not specifically labeled for IBS, lubiprostone is indicated for idiopathic constipation. It has chloride channel action that draws fluid into the bowel and causes a motility effect.
"The dosage is 24 micrograms twice daily with food," she said. "I tell my patients to take the pills when they take the first bite of food so they don't take it too early. This helps lessen the chance of nausea. "
Probiotics, dietary supplements that contain potentially beneficial bacteria or yeast "appear to be helpful in treating constipation," said Pallentino. "Most of the research shows some improvement and that is encouraging."
Fiber and antispasmodics also have a role in treating diarrhea associated with IBS. Antidiarrheal drugs, including over-counter medications such as loperamide, work well for many patients.
"Although off-label, the bile sequestrant colesevelam has worked in patients with explosive diarrhea," said Pallentino. "One or two tablets a day at breakfast and dinner to start and adjust up or down according to symptoms."
Alosetron is a medication labeled for treatment of severe, diarrhea-predominant IBS if all other treatments fail. Because of the risk of ulcerative colitis, the drug is available through limited use-only approved physicians. There is a detailed patient warning and signed consent form that must be used. Careful control and frequent monitoring is required.
"Although alosetron is technically available, the paperwork involved and the few physicians that are approved to prescribe it, make the drug unavailable to most patients," said Pallentino.
The only medication with an indication for IBS constipation, tegaserod was withdrawn from the market at the request of the Food and Drug Administration in March. It was associated with a higher risk for serious cardiovascular adverse events when compared with placebo. Whether it will become available again and under what conditions is still unknown, said Pallentino.
"IBS is a chronic condition that severely affects the quality of life," said Pallentino. "It is very amenable to treatment currently and the future holds hope that there may soon be other agents to address the effects of IBS."
| Pallentino disclosed financial support from Novartis Pharmaceuticals, Sucampo Pharmaceuticals, Takeda Pharmaceuticals North America, AstraZeneca, Proctor & Gamble, and Roche. |
Primary Source
American Academy of Nurse Practitioners Annual Meeting
Source Reference: "The ABCs & Ds of IBS"