Therapeutic Management of Irritable Bowel Syndrome in Primary Care - Literature review Example

Therapeutic Management of Irritable Bowel Syndrome in Primary Care of 1670 Words Pathophysiology and Clinical Manifestations Irritable bowel syndrome (IBS) is a disorder of the colon characterised by excessive gas, cramping, abdominal pain, bloating, diarrhoea and constipation. It is a chronic disease that requires long-term management (Adeniji et al., 2004). Although it does not result in bowel tissue changes, it has quite painful symptoms, different other similar conditions such as colitis and Crohn’s disease. In addition, IBS does not amplify a patient’s risks of contracting colorectal cancer. Only a few cases of IBS portray severe signs and symptoms. In fact, in some cases, patients are able to control their symptoms through lifestyle changes, stress and diet management (Adeniji et al., 2004). Nonetheless, many of the cases of IBS need psychotherapy and medication. The condition manifests in several ways in different patients. Its common signs and symptoms are abdominal pain, spasm, bloated feeling, diarrhoea, constipation and gas (Adeniji et al., 2004). The severity of the symptoms varies from mild to chronic. A patient should visits a doctor every time changes in bowel habits are unrelenting or when other signs or symptoms of IBS indicating the likelihood of more serious conditions such as colon cancer are observed (Cash & Chey, 2005). Symptoms of other IBS-related conditions are rectal bleeding, abdominal pain, which is more severe at night and weight loss. Therapeutic Management Study on the effectiveness of Antimuscarinic antispasmodic Quartero et al (2005) studied the efficacy of Antimuscarinic antispasmodic and antidepressant medicine on IBS. The study’s objective was the evaluation of the drugs’ efficacy on the symptoms irritable bowel syndrome. One of the studies targeted 59 patients, all of whom reported a discontinuous improvement in abdominal pain. In another study, 128 participants reported uninterrupted improvement of abdominal pain. The study concluded that the drug is quite effective in IBS, especially abdominal pain. Nonetheless, it was not clear whether the antispasmodic drug was effective on its own (Quartero et al., 2005). On the other hand, there was not clear evidence of benefits for antidepressants and bulking agents which were studied together with the antimuscarinic antispasmodic (Quartero et al., 2005). Study on the effectiveness of Ispaghula Husk on IBS Kumar et al (1987) conducted a study on the optimum and effective dosage of Ispaghula Husk in patients with IBS and the relationship between symptom relief and whole gut passage time and stool mass. In the first part of the study, 14 male patients took increasing dosages of 10 g, 20 g, and 30 g daily for 17 days. The symptoms of IBS considerably improved for the ten people that completed the study. The 20 g and 30 g doses of Ispaghula recorded better improvements than the 10 g dose (Kumar et al., 1987). However, the difference between the 20 g and 30 g doses were inconsequential. Besides a considerable rise in the daily stool mass with the 10 g, 20 g and 30 g doses, a positive relationship was noted between the improvement in the symptom score and the rise in stool weight for the 10 g dose of Ispaghula Husk but not with the 20 g and 30 g doses (Kumar et al., 1987). Study on the effectiveness of Hyoscine N Butylbromide (Buscopan) on IBS In a study published in the 3rd issue of the 33rd volume of Clinical Radiology, Lee, J R studied the effectiveness of routine use of Hyoscine N Butylbromine in double contrast barium enema examinations. This study analyzed the effects of both oral and intravenous administration of Buscopan on the signs and symptoms of the large bowel in double contrast barium enema (DCBE) examination, compared corresponding measurements without Buscopan (Lee, 1982). The researcher established that whereas 20 mg oral Buscopan did not change the dimensions of the colon, 20 mg of Buscopan administered intravenously caused significantly greater distension of the colon (Lee, 1982). In fact, the colonic length increased following intravenous Buscopan. However, the increase was to a slight extent. It was found out that orally administered Buscopan is less effective compared to the intravenously administered (Lee, 1982). In addition, no side effects were reported with intravenous Buscopan. This finding was replicated in elderly patients too. The study concluded that intravenously administered Buscopan seems safe and effective for use during DCBE examinations (Lee, 1982). Pharmacist’s Contribution to Patient Care A pharmacist’s contribution to the care of an IBS patient is viewed mainly with reference to medication. However, a pharmacist may combine medicine with recommendations for lifestyle changes to assist IBS patients manage the signs and symptoms of the condition (Agrawal & Whorwell, 2006). Hyoscine Butylbromide (Buscopan) Important Caution: A patient to be placed under this medication should inform the doctor on her/his medical history for conditions such as glaucoma, other eye problems, heart disease and enlarged prostate in males. Caution is similarly given to patients suffering from allergies and stomach or intestinal diseases. The medication should also only be used in pregnancy when absolutely necessary. Patients should also discuss the risks and benefits of this medication with their doctor. It is not clear if this medication is excreted into human milk. Hence, a patient should seek the doctor’s advice prior to breast-feeding. Caution is advised for elderly patients using this drug. Interactions The drug may react with other medications that a patient might be taken. Thus, the patient should inform the doctor on these non-prescription or prescription medications. A particular drug with which this medication interacts is tricyclic antidepressants and MAO Inhibitors such as phenelzine, linezolid, tranylcypromine, isocarboxazid, selegiline, furazolidone), quinidine, amantadine. Patient Education The drug should be stored at room temperature, away from heat, light and moisture. In case of overdose, a patient should contact the local poison control agency and emergency room immediately. Different countries have poison or emergency hotlines that cases of overdose are reported. Symptoms of overdose that patients should look out for are dry mouth; excessive thirst; vomiting; difficulty breathing; unclear vision; dilated pupils; flushed, hot, dry skin; muscle weakness; dizziness or drowsiness; restlessness; disorientation; and seizures. A missed dose should be taken as soon as remembered. However, if it is quite close to the next dose, the missed dose should be skipped and the usual dosing calendar resumed. Ispaghula Husk Patient education The medication is indicated for chronic constipation; ulcerative colitis and irritable bowel syndrome. The dosage for adults and children aged 12 years and above is 30g daily, divided into doses of 2.5 to 7.5 grams per dose, mixed in 8 oz of water or juice. The liquid should be preferably cold and tasty to mask the taste of drug. Take diluted medicine immediately after mixing because it might thicken. Patients should monitor their bowel movements and look out for signs and symptoms of severe allergic reactions, which are rare such as anaphylaxis and asthma. The medication should be taken after meals in case the drug decreases a patient’s appetite. Caution Some patients could be hypersensitivity to drug, which might result in intestinal obstruction, abdominal pain, appendicitis pain and fecal impaction. The medication should also be used cautiously in cases of phenylketonuria and pregnancy. Patients are advised not to take the drug without first dissolving it. All the significant and life-threatening adverse reactions should be reviewed. Interactions and adverse reactions Despite having none significant interactions, the medication has adverse reactions on the gastrointestinal system and the respiratory system. In the GI, the drug’s reaction is epitomised by nausea, vomiting, abdominal cramps, severe constipation and anorexia (Wood et al., 2000). If used excessively, diarrhoea may occur. It may also result in gastric, rectal, small intestine and oesophageal obstruction. Other allergic reaction is anaphylaxis and rare cases of asthma. Loperamide Loperamide, an opioid derivative of piperidine is a common medication against IBS. The drug treats the symptoms of diarrhoea such as traveller’s diarrhoea by acting on fluid and electrolyte transport, through opiate agonism, calcium-channel blocking, calmodium inhibition and para-cellular permeability, colon is the main site of action (Ooms et al., 1984). Patient education Patients are advised to use Loperamide as directed by doctor, keenly checking the label for exact dosage and other instructions. Loperamide is administered through the mouth with or without food (NICE, 2014a). Patients placed under Loperamide should drink extra fluids, especially in case of diarrhoea. Any missed dosage should be taken as soon as possible. Patients should also check with the doctor in case of questions. Side Effects Pharmacists also monitor for reduced side effects because recent studies suggest that Loperamide is more effective and has less neural side effects compared to IBS medications. Pharmacists who prescribe this medication also take extra caution to monitor advanced HIV patients more keenly because of reported cases of viral and bacterial megacolon. The medication has no common side effects. However, its severe side effects include rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); constipation; decreased urination; red, swollen, blistered, or peeling skin; stomach bloating, swelling, or pain. However, the medication is not suitable for patients that are allergic to Loperamide ingredients or those with stomach pain but without diarrhoea. It also reacts negatively in patients with constipation; stomach bloating, bloody stools; or dark and tarry stools (Netdoctor.co.uk, 2014). Interactions The medicine interacts with cases pregnancy, plans for pregnancy, breast-feeding and those taking prescription or non-prescription medicine, herbal preparation, or dietary supplement. It also interacts with allergies to medicines, foods, bloody diarrhoea; mucus in stool; fever and bowel problems such as inflammation, blockage, enlarged colon or diarrhoea caused by food poisoning, antibiotic use, or bacterial infection (Agrawal & Whorwell, 2006). It is also interactive with AIDS or liver problems and patients under antibiotics. Conclusion The effective management of irritable bowel syndrome requires the input of patients, physicians and pharmacists. First, a person with irritable bowel syndrome should give all necessary information on the condition to the physician and the pharmacist. After the disclosure of this information, all the stakeholders in IBS management should work together to manage and treat the condition (NICE, 2014b). The main IBS management approaches include healthy diet, physical activity, first-line pharmacological treatment and the use of complementary and alternative medicines. In some cases, referral to a dietician is recommended. In more serious cases, second-line pharmacological treatment is advised. Opioid, laxatives and relaxing medicines are the main modes of IBS treatment. Examples of these types of medication are Loperamide, Ispaghula husk hyoscine and butylbromide respectively. References Adeniji, O. A., Barnett, C. B., and Di Palma, J. A. (2004) “Durability of the Diagnosis of Irritable Bowel Syndrome Based on Clinical Criteria.” Digestive Diseases and Sciences, 49(4): 574. Agrawal, A., and Whorwell, P. J. (2006) “Irritable Bowel Syndrome: Diagnosis and Management.” British Medical Journal, 332(7536): 280. Cash, B. D., and Chey, W. D. (2005) “Diagnosis of Irritable Bowel Syndrome. Gastroenterology Clinics of North America, 34(2): 205. Kumar, A., Kumar, N., Vij, J. C., Sarin, S. K., and Anand, B. S. (1987) “Optimum Dosage of Ispaghula Husk in Patients with Irritable Bowel Syndrome: Correlation of Symptom Relief with Whole Gut Transit Time and Stool Weight.” Gut, 28(2):150. Lee, J. R. (1982) “Routine Use of Hyoscine N Butylbromide (Buscopan) In Double Contrast Barium Enema Examinations.” Clinical Radiology, 33(3):273-6. Netdoctor.co.uk (2014) “Buscopan: How Does It Work?” Retrieved on December 9, 2014 from http://www.netdoctor.co.uk/diet-and-nutrition/medicines/buscopan.html NICE (2014a) “Diagnosis and Management of Irritable Bowel Syndrome in Primary Care.” Retrieved from https://www.nice.org.uk/guidance/cg61/resources/cg61-irritable-bowel-syndrome-algorithm-of-ibs-diagnosis-and-management-within-primary-care2 NICE (2014b) “Managing Irritable Bowel Syndrome.” Retrieved on December 10, 2014 from http://pathways.nice.org.uk/pathways/irritable-bowel-syndrome-in-adults#path=view%3A/pathways/irritable-bowel-syndrome-in-adults/managing-irritable-bowel-syndrome.xml&content=view-node%3Anodes-first-line-pharmacological-treatment/ Ooms, L. A., Degryse, A. D., and Janssen, P. A. (1984) “Mechanisms of Action of Loperamide.” Scandinavian Journal of Gastroenterol Supplement, 96:145-55. Quartero, A. O., Meiniche-Schmidt, V., Muris, J., Rubin, G., and Wit, N. (2005) “Bulking Agents, Antispasmodic and Antidepressant Medication for the Treatment of Irritable Bowel Syndrome (Review). The Cochrane Library. Wood, A. J. et al. (2000) "Increased Drug Delivery to the Brain by P-glycoprotein Inhibition.” Clinical Pharmacology and Therapeutics, 68(3): 237. Read More