ibs enhanced primary care pathway [july 2016]
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Name:
DOB:
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RefMD: Dr.
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DateToday: CONFIRMATION: ReferralReceived
IBSTRIAGECATEGORY: EnhancedPrimaryCarePathway
REFERRALSTATUS: CLOSEDDearDr.,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithirritable bowel syndrome (IBS). Based on full review of your referral, it has been determined thatmanagementof thispatientwithin theEnhancedPrimaryCarePathway isappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:
1. FocusedsummaryofIBSrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail
ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.If your patient completes the Enhanced Primary Care Pathway and remains symptomatic or ifyourpatient’sstatusorsymptomschange,anewreferralindicating‘completedcarepathway’or‘newinformation’shouldbefaxedtoGICentralAccessandTriageat403-944-6540.Thankyou.
KevinRioux,MDPhDFRCPCMedicalLead,GICentralAccessandTriageSectionofGastroenterology
Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME March 2016 - Page 2/6
EnhancedPrimaryCarePathway:IBS
1.FocusedsummaryofIBSrelevanttoprimarycare
Irritablebowelsyndromeisacommonsymptomcomplexcharacterizedbychronicabdominalpainandabnormalbowelfunctioninabsenceoforganiccause.ThesekeyfeaturesofIBScanbewidelyvariableinseverityandmayremitandrecur,oftenbeingaffectedbydietaryfactorsandvariousstressors.Reliefof abdominal discomfort after bowel movement is a defining feature. Bowel dysfunction includesfrequent bowel movements, fecal urgency and even incontinence, altered stool form (hard/lumpy orloose/watery),incompleteevacuation,strainingatstool,andpassageofcopiousmucus.IBSisfrequentlyassociatedwithothergastrointestinalsymptomsincludingbloating,flatulence,nausea,burping,earlysatiety,gastroesophagealreflux,anddyspepsia.Extra-intestinalsymptomsalsofrequentlyoccurinIBSpatientsincludingdysuriaandfrequent,urgenturination,widespreadmusculoskeletalpain,dysmenorrhea,dyspareunia,fatigue,anxiety,anddepression.DiagnosticcriteriaforIBS(e.g.RomeIV)weredevelopedforuniformityofpatientrecruitmentinclinicaltrials. Inclinicalpractice,suchcriteriaonlyprovidea framework forassessingpatientswithsuspectedIBS;indeedthesecriteriaalonearefarbetterforrulingoutIBSthanrulingitin.TheconfidentdiagnosisofIBSreliesonpresenceoffoundationalsymptoms,recognitionofintestinalandextra-intestinal symptomsandpsychological stressors that support the IBSdiagnosis,detailedmedicalhistoryandphysicalexaminationaswellas judicioususeof investigations to identify red flag featuresandexcludeorganicconditionsthatmimicIBS.Treatment of IBS involves initial reassurance, dietary, psychological, behavioral interventions,pharmacotherapy based on dominant symptoms, and scheduled patient clinical review, reappraisal,support,andguidance.2.Checklisttoguideyourin-clinicreviewofthispatientwithIBSsymptoms
o RomeIVcriteriaforIBS:Recurrentabdominalpain≥1dayperweekinthelastthreemonthsrelatedtodefecationorassociatedwithchangeoffrequencyand/orform(appearance)ofstool.
o Absenceofredflagfeatures(bleeding,anemia,weightloss,nocturnalorprogressivesymptoms,onsetafterage50)
o Nofamilyhistoryofinflammatoryboweldisease,colorectalcancer,orceliacdisease
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EnhancedPrimaryCarePathway:IBS3.Linkstoadditionalresourcesforpatients
CanadianDigestiveHealthFoundationUnderstandingIrritableBowelSyndromehttp://www.cdhf.ca/en/disorders/details/id/12
UpToDate®–BeyondtheBasicsPatientInformationaboutIBS(freelyaccessible)http://www.uptodate.com/contents/irritable-bowel-syndrome-beyond-the-basics?source=search_result&search=ibs&selectedTitle=2%7E1504.Clinicalflowdiagramwithexpandeddetail
This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofIBS,frombothGastroenterologyandPrimaryCareliterature:
DrossmanDAandHaslerWL.RomeIV—FunctionalGIdisorders:Disordersofgut-braininteractionGastroenterology2016;150:1257-61http://www.gastrojournal.org/issue/S0016-5085(15)X0019-9Weinbergetal.AGAInstituteGuidelineonthepharmacologicalmanagementofirritablebowelsyndrome.Gastroenterology2015;147:1146-8http://www.gastrojournal.org/article/S0016-5085(14)01089-0/abstract
KuritzkyL.IndividualizingPharmacologicManagementofIrritableBowelSyndrome.JFamPract.2015;64:S16-21.http://admin.imng.com/fileadmin/qhi/jfp/pdfs/CME_-_Hot_Topics_IBS_article_2.19.16.pdf
Wilkinsetal.DiagnosisandmanagementofIBSinadults.AmericanFamilyPhysician2012;86:419-426http://www.aafp.org/afp/2012/0901/p419.html
The following is a best-practice clinical care pathway for management of irritable bowelsyndrome in the primary care medical home, which includes a flow diagram and expandedexplanationoftreatmentoptions:
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FlowDiagram:IBSDiagnosisandManagement-ExpandedDetail1. Diagnosis of IBS isbasedonRome IV criteria (2016)of abdominalpain related todefecationand
associated with change in stool frequency or form. IBS requires very little initial laboratoryinvestigation – CBC, ferritin, and celiac disease screen according to most guidelines. The fecalimmunochemical test (FIT)hasnotbeenvalidated for investigationof IBS-likesymptoms;orderingFITinthiscircumstanceisinappropriate.Anemiaorotherredflagfeaturesincreasethelikelihoodoforganic disease and mandate referral to GI. Absence of red flags, however, does not completelyexcludethepossibilityoforganicdisease.Variousother intestinalandextraintestinal featuresoftenco-exist with IBS and provide support to the diagnosis. It is estimated that unrecognized organicdisorderswillbepresentinabout15%ofpatientswhomeetRomeIVcriteriaanddonothavealarmfeatures.Themost commondiseases that aremislabeledas IBSare celiacdisease,Crohn’sdisease,andmicroscopiccolitis. If C-reactive protein is ≤ 0.5mg/dL, the probability of IBD is ≤1%.GIcancersareveryunlikelyinpatientsthatmeetusualcriteriaforIBS.Adetailedmedicalhistoryandphysicalexaminationshouldbeperformedatpresentationtoassessfor a multitude of other conditions that mimic IBS. A careful review of medications should beperformed to identify ones that may be causing GI side effects (e.g. PPI, ASA/NSAIDs,laxatives/antacids, iron/calcium/magnesium supplements, calcium channel blockers,antidepressants,opioids,diuretics,herbalproducts).
2. General principles of IBS treatment. All patientswith IBSwill benefit from lifestyle and dietarymodifications,andthismaybeallthatisrequiredinthosewithmildorintermittentsymptomsthatdo not affect quality of life. Key to long-term effective management of IBS is to provide patientreassuranceoftheinitialdiagnosisIBSandofferpointsofreassessmentandreappraisaltoestablishatherapeuticrelationship.Connectingpatientswithresourcesfordiet,exercise,stressreduction,andpsychologicalcounselingisimportant.Screenforandtreatanyunderlyingsleepormooddisorder.
3. Specific approaches based on IBS subtype.Thereare threeclinicalphenotypesof IBS:diarrhea-
predominant(IBS-D),constipation-predominant(IBS-C),andmixedpatternalternatingdiarrheaandconstipation (IBS-M). Categorizing IBS by dominant GI symptom guides focused use of a fewadditionalinvestigations(particularlyinIBS-D),butalsoguidesspecifictreatmentapproaches.UseofpharmaceuticalsinIBSisgenerallyreservedforthosewhohavenotadequatelyrespondedtodietaryandlifestyleinterventions,orinthosewithmoderateorseveresymptomsthatimpairqualityoflife.Pain and bloating is a defining feature of IBS and, in some patients, these features are severe orfrequentenough toaffectqualityof life.Antispasmodicsmaybebeneficial inmanagingorabortingacute episodes of pain, andpatients often take reassurance in having these on-demand treatmentsavailable. For chronic IBS pain, tricyclic antidepressants have shown benefit, andmay have addedbenefitsinthosepatientswithmoodorsleepissues.In absence of alarm features, what would prompt referral for GI consultation and possiblecolonoscopy? Colonoscopy may be helpful in patients with diarrhea predominance who havepersistent symptomsor limitedbenefit fromusual treatments.This ismainly to assess forCrohn’sdiseaseandmicroscopiccolitis. Inpatientswithconstipationpredominanceoralternatingdiarrheaandconstipation,colonoscopyisveryunlikelytoyieldrelevantfindings.
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PrinciplesandSpecificsofIBSManagementbySubtype
AllsubtypesofIBS
Exercise Moderatetovigorousexercisefor20-60minutes3-5xperweek
SolubleFibreUseinIBSremainscontroversial,asmaybebeneficialinsomebutdetrimentalinothers.Reasonabletotrypsylliumhuskone-halftoonetablespoondaily.Insolublefibrelikebranisnotbeneficial.
Probiotics Bifidobacteriuminfantis(Align®)1capsule/d($40/mo.)Lactobacillusplantarum229v(TuZen®)1-2capsules/d($40-80/mo.)
Antispasmodics
Peppermintoil(0.2to0.275mLcaps,entericcoated)2capsulesBID($20-25/mo.)HyoscineButylbromide(Buscopan®)10mgTID-QID($25-40/mo.)Dicyclominehydrochloride(Bentylol®)20mgTID-QID($25-40/mo.)PinaveriumBromide(Dicetel®)50-100mgTID($50-75/mo.)Trimebutine(Modulon®)100-200mgTID($40-80/mo.)Allprescribedantispasmodicmedicationsshouldbefullydiscussedwiththepatientintermsofspecificrisksandsideeffectsandappropriatenessofuseincontextoftheirfullmedicalhistory
Antidepressants
Nortriptylineoramitriptyline10-25mgqhs,doseescalateby10-25mg/wkMayrequire25-150mg/d($20-60/mo.);usuallytakes2-3mos.forpeakeffectParticularlyusefulinpatientswithdiarrheaandpainpredominanceorsleepissues/anxiety/depressionUsewithcautioninpatientsatriskofprolongedQT;notesomnolenceandanticholinergicsideeffectsLatestIBStechnicalreviewdoesnotendorseuseofSSRIs
ComplementaryTherapies
PsychologicaltreatmentsMindfulness-basedstressreduction(www.thebreathproject.org)HypnotherapyAccupunctureYoga(www.yogacalgary.ca)
Diarrhea-PredominantIBS
Antidiarrheals
Loperamide(Imodium®)2-4mgBID($25-50/mo.OTC)Cholestyraminepowder(Olestyr®$0.40/g),colestipol(Colestid®$0.25/g)tabletsorpowderorcolesevelam(Lodalis®$1.80/g)tabletsorpowder,1-4gpoOD-TIDEspeciallyusefulpost-cholecystectomy.Adviseregardingtimingwithothermedicationstoavoidinteraction;iflongtermuse,riskoffatsolublevitamindeficiencies
FODMAPs CanadianDigestiveHealthFoundationcdhf.ca/bank/document_en/32-fodmaps.pdf
GlutenAvoidance Nonceliacglutensensitivity
Antibiotics Rifaximin(Zaxine®)550mg3x/dailyfor2weekswhichcosts~$325!
Constipation-PredominantIBS
PEG-basedLaxatives Mira-Lax®orLax-a-Day®17-34g/d($25-50/mo.)
Prokinetics Linaclotide(Constella®)290µg/d30minutesbeforebreakfast($160/mo.)Prucalopride(Resotran®)2mg/d,4weektrial($120/mo.)
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