Expertise of Compounding Pharmacists Guide Patient Treatment for Irritable Bowel Syndrome
Mention irritable bowel syndrome and people tend to shrug and wonder why all the fuss about common problems like diarrhea and constipation. They just don’t get the discomfort and distress. For some IBS patients, the struggle includes being afraid to leave home for fear of unexpected diarrhea attacks. Another embarrassment may be daily “gas incontinence.” Self-image, social life and the ability to work are all on the line for these patients. Since many may avoid consulting their physician, compounding pharmacists need to stay up-to-date with new research and help them find appropriate treatment for irritable bowel syndrome.
The Impact of Irritable Bowel Syndrome
The overall prevalence of irritable bowel syndrome is estimated to be 10 to 20 percent.1 It’s often first diagnosed in adolescence or early adult life, which is reflected by a rate of 13 to 38 percent for this age group.2 But the impact of IBS is bigger than hinted at by these numbers. It persists for years, with more than half of IBS patients reporting the same symptoms after seven years. In the year following their diagnosis, IBS patients have a higher incidence of colorectal cancer. Within three years, they’re nine to 16 times more likely than the general population to be diagnosed with inflammatory bowel disease. Comorbidities that occur in half of those with IBS include:
- Chronic fatigue syndrome
- Chronic back and pelvic pain
- Temporomandibular joint dysfunction
- Chronic headaches, including migraines
A study presented at the American Academy of Neurology meeting in April 2016 suggested the possibility of a genetic link between migraines and IBS. When the serotonin transporter and serotonin receptor 2A genes were analyzed, researchers found that subjects with IBS and migraine had at least one gene that differed from healthy participants. In the study, 35.5 percent of patients with IBS had migraine headaches and half of patients with migraines were diagnosed with IBS.3
Diagnostic Criteria and Changes to Come in Rome IV
The Rome III diagnostic criteria state that abdominal pain must occur at least three days per month over the previous three months. Abdominal discomfort must be associated with at least two of the following:
- Onset associated with change in stool frequency
- Onset associated with change in stool form or appearance
- Relieved by defecation
- Altered stool passage, such as straining or urgency
- Mucus in stool
- Abdominal bloating or distention
For the first time in ten years, revised diagnostic criteria—Rome IV—will launch in May 2016. Rome IV explores how we can begin to eliminate the functional-organic dichotomy and consider IBS-associated abnormalities in mucosal immune function and the microbiota. Additionally, it introduces a multi-dimensional clinical profile so that clinicians can better synthesize the diverse range of symptoms, psychological comorbidities and the degree of physiological dysfunction.4
Pharmaceutical Treatment for Irritable Bowel Syndrome
Since altered bowel function includes diarrhea and/or constipation, the syndrome is subtyped into four patterns:
- IBS-D (diarrhea predominant)
- IBS-C (constipation predominant)
- IBS-M (mixed diarrhea and constipation)
- IBS-A (alternating diarrhea and constipation)
Multiple pharmaceutical options are available to treat the various subtypes:
- Anticholinergics: dicyclomine and hyoscyamine
- Antidiarrheal: loperamide and diphenoxylate
- Bulk-forming laxatives
- Antispasmodics (peppermint oil, pinaverium, trimebutine, cimetropium)
- Serotonin receptor antagonists: alosetron
- Chloride channel activators: lubiprostone
- Guanylate cyclase C agonists: linaclotide
- Antibiotic: rifaximin
- Mixed opioid effects: eluxadoline
- Tricyclic antidepressants: amitriptyline and imipramine
The off-label use of tricyclic antidepressants to treat pain has been increasing in recent years and they may offer relief for IBS. A meta-analysis of 12 randomized controlled trials published in August 2015 found that treatment with tricyclic antidepressants improved global IBS symptoms.5
Potential New Role for Common Antihistamines
An association between histamine and gut pain was recently discovered when researchers found that TRPV1 on submucosal neurons is sensitized by high levels of histamine in people with IBS. They subsequently conducted a clinical trial with 55 IBS patients randomized to receive a placebo or ebastine. After 12 weeks, patients taking ebastine, but not the placebo, had significantly less pain and could sleep better, reported Gastroenterology in April 2016.6
Two points from the study are especially important. First, tests verified that ebastine’s benefits were not caused by its potential to inhibit inflammation. Second, the study was designed to prove the connection, not to establish clinical end points. Even though the degree of abdominal pain relief achieved by ebastine was comparable to linaclotide, the full extent of its therapeutic impact must be determined in future clinical trials.
Pharmacist Expertise Guides Undiagnosed Patients
Relentless pain and unpredictable bowel symptoms cause chronic stress and ultimately severe depression in IBS patients. In spite of its impact, nearly 70 percent of people with symptoms don’t visit their doctor. But they’re definitely in your pharmacy looking for OTC products to treat their symptoms. Guiding them to the best treatment is imperative, but it requires sensitive outreach since many people don’t like to discuss bowel habits. Here are a few outreach ideas:7
Attract attention: Put up a simple poster stating, “Do you have recurrent abdominal pain, diarrhea or constipation? Ask the pharmacist about Irritable Bowel Syndrome.”
Assess for IBS: Refer patients to a doctor if symptoms fit the IBS criteria or if they have rectal bleeding, fever or unintended weight loss. Watch for red flags like a family history of celiac sprue, inflammatory bowel disease or colorectal cancer.
Review medications: Make sure they don’t take medications that may cause diarrhea or constipation, such as antibiotics, anti-inflammatory drugs, opioids, antidepressants, anticonvulsants, antihistamines and endocrine or gastrointestinal agents.
Provide info about diet, probiotics and therapeutic treatment: While you don’t have enough time to delve into all possible treatments, be prepared to hand out information about:
- Diet: Patients need to figure out which foods may trigger IBS symptoms, which is best done together with their physician or a registered dietitian.
- Probiotics: Not all probiotics are beneficial but evidence supports the use of multiple Bifidobacterium and Lactobacillus strains for relieving IBS symptoms.8
- Psychotherapy: A meta-analysis in the December 2015 issue of Clinical Gastroenterology and Hepatology found that psychological therapy was beneficial and that the effects lasted six to 12 months after therapy ended.
Targeted Treatment for Irritable Bowel Syndrome
Irritable bowel syndrome is anything but simple to diagnose and medical treatment sometimes becomes a matter of trial-and-error that leaves patients frustrated and suffering for years. Compounding pharmacists who successfully reach out to IBS patients stand to build a loyal customer base while making a substantial difference in the quality of treatment for irritable bowel syndrome.
Pharmaceutica North America is a leading provider of pharmaceutical ingredients, including antidiarrheals and TCAs used to treat IBS. Please contact us today to talk about how our compounding kits and APIs can meet your patient’s needs and support your pharmacy.
- “Irritable Bowel Syndrome,” June 2015, http://emedicine.medscape.com/article/180389-overview ↩
- “Irritable Bowel Syndrome in Children and Adolescents,” May 2015, http://www.uspharmacist.com/content/d/feature/c/54513/ ↩
- ”Migraine Linked to Irritable Bowel Syndrome,” March 2016, http://www.medscape.com/viewarticle/859763 ↩
- “Rome IV FAQs,” 2016, http://www.romecriteria.org/romeiv_pub/romeiv_faqs.cfm ↩
- “Efficacy and Safety of Antidepressants for the Treatment of Irritable Bowel Syndrome: A Meta-Analysis, August 2015, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529302/ ↩
- “Histamine Receptor H1-Mediated Sensitization of TRPV1 Mediates Visceral Hypersensitivity and Symptoms in Patients with Irritable Bowel Syndrome,” April 2016, http://www.gastrojournal.org/article/S0016-5085(15)01862-4/pdf ↩
- “Counseling Tips for Patients with Irritable Bowel Syndrome,” February 2010, http://www.pharmacytimes.com/publications/issue/2010/february2010/counselingibs-0210 ↩
- “The Intestinal Microbiota and the Role of Probiotics in Irritable Bowel Syndrome: A Review,” December 2015, http://www.scielo.br/pdf/ag/v52n4/0004-2803-ag-52-04-00331.pdf ↩