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WELL Duquesne University Mylan School of Pharmacy

UPDATE from the Center for Pharmacy Care

January-February 2005

Irritable Bowel Syndrome A Common Problem for Women

I

rritable bowel syndrome (IBS) is a chronic, non-specific disorder of the colon (large intestine) that affects up to 20 percent of the U.S. population. The condition is two to three times more likely in women and accounts for nearly one in 10 physician visits. Its typical onset is approximately 20 years of age. However, it has been suggested that a significant number of the elderly can be troubled by IBS symptoms. IBS does not cause inflammation or destructive changes in bowel tissue nor does it increase the risk of colorectal cancer. There currently does not appear to be a link between IBS and inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis. IBS is not a disease, but rather a syndrome that may appear as a combination of signs and symptoms. Most people (70 percent) may only have mild signs and symptoms of IBS; whereas others (5 percent) have severe complaints that often do not respond well to medical treatment.

Women account for nearly 80 percent of the cases of severe IBS. For the majority of patients, IBS is a chronic condition, characterized by varying periods of remission. During the course of the syndrome, signs and symptoms may unexpectedly get worse. At other times, they improve or even disappear completely.

IBS Symptoms • Abdominal pain or • Mucous in the stool cramping • Fatigue • Bloating • Pelvic pain • Gas (flatulence)

• Straining of the stool • Diarrhea or • Feeling of incomplete constipation evacuation (some patients experience alternat- • Sexual dysfunction • Urologic or gynecoing diarrhea and logic complaints constipation)

What Causes IBS? The walls of the large intestine are lined with layers of muscle that contract and relax as food passes from the stomach through the intestinal tract. In most cases, these muscles move in a syncopated or coordinated rhythm. In IBS patients, the contractions can become more forceful and prolonged. As a result of more rapid food transfer, gas, bloating and diarrhea often occur. If the force and frequency of contractions are reduced, food passage is slow and the stools become hard and dry. The exact cause of IBS is unknown, but some researchers suggest it is caused by changes in the nervous system that controls sensation and muscle contractions in the bowel. Others believe that patients with IBS have intestinal tracts that are more sensitive and reactive than usual to a variety of items including certain foods and stress. Because women are more likely to continued on back

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IBS a common problem in women experience IBS than men, hormonal changes may also play a role in its development. Stress itself does not cause IBS, but it can initiate and worsen symptoms.

How is IBS Diagnosed? A diagnosis of IBS is primarily based on a complete medical history, physical exam and laboratory tests. It is possible that your doctor may recommend several tests, including stool studies, to check for infection or malabsorption problems. Some doctors also may suggest sigmoidoscopy (a procedure that uses a flexible tube to examine the lower part of the colon), colonoscopy (visual evaluation of the entire length of the colon), or endoscopy (examination of the upper part of the gastrointestinal tract). These tests are beneficial to rule out more serious conditions such as ulcerative colitis, Crohn’s disease and colorectal cancer. An x-ray taken after administration of barium may help to improve visualization of the bowel. Other tests may be performed to rule out lactose intolerance and celiac disease. Because there are rarely any specific laboratory tests or signs of disease in IBS, diagnosis is often a process of elimination. To aide in this process, researchers have established diagnostic criteria (“Rome II Criteria”) for IBS and other functional gastrointestinal disorders. In accordance with these criteria, the patient must have certain signs and symptoms before a diagnosis of IBS can be made. The most critical criteria are abdominal pain and diarrhea or constipation lasting at least three months. At least two of the following features also must be included: relief of symptoms after defecation, onset associated with a change in frequency of stool, and onset associated with changes in the form (appearance) of stool. The most frequent clinical feature in IBS is a change in bowel habits. Constipation generally alternates with diarrhea with one of these symptoms usually predominating. Heartburn, chest pain, headache, fatigue, gynecological symptoms, anxiety, or depression may accompany the classic criteria of IBS.

Treatment Options There is currently no cure for IBS, but many options are available for managing the signs and symptoms associated with the syndrome. In many instances, simple changes in diet and lifestyle may be sufficient to provide relief from IBS.

Lifestyle Changes • Avoid known triggers • Fiber supplementation • Avoid problem foods • Eat at regular times • Exercise regularly • Drink plenty of liquids • Use antidiarrheals and laxatives with caution

Alternative Therapies • Acupuncture • Progressive relaxation exercises • Massage, meditation, deep breathing • Herbs

Pharmacologic Therapy IBS patients who do not respond to diet and lifestyle modifications may need pharmacologic intervention. Fiber supplements such as psyllium (Metamucil, etc.), methylcellulose (Citrucel, etc.) and polycarbophil (Mitrolan) may be beneficial when constipation is a predominant complaint. However, these supplements as well as dietary bran fiber may worsen intestinal gas, bloating and abdominal discomfort. Antidiarrheal agents, such as loperamide (Imodium), are effective in reducing stool frequency and urgency. Dicyclomine (Bentyl, etc.) and hyoscyamine (Levsin, etc.) may be useful for

Newsletter Contributors John G. Lech, Pharm.D. Katie E. Heffner, Pharm.D. Candidate Allan C. Haddad, Jr., Pharm.D. Candidate

Additional information regarding IBS may be obtained by visiting the following Web sites: • www.digestive.niddk.nih.gov/ddiseases/pubs/ibs/

• www.mayoclinic.com

• www.acg.gi.org/patients/patientinfo/ibs.asp

• www.ibsassociation.org/

acute episodes of pain or bloating. Because side effects are common, these drugs should be used cautiously in the elderly and in patients with constipation. Serotonin (also known as 5-hydroxytryptamine or 5-HT) plays a key role in contractility and relaxation of the gastrointestinal tract. Drugs that affect subtypes of 5-HT are useful in treating IBS associated with diarrhea or constipation. Alosetron (Lotronex), a blocker of 5-HT3, is used in treating female patients with diarrhea-predominant IBS. It was approved by the FDA in November 2000 as the first drug specifically indicated for the management of moderate to severe symptoms of IBS with diarrhea in women. Unfortunately, it was withdrawn from the market nine months later after several reports of serious adverse effects and some deaths. Many of these cases were due to the inappropriate use of alosetron. The drug was reintroduced into the market in 2002 with new warnings limiting its use to treatment of women with severe diarrhea-predominant IBS who failed to respond to conventional therapy. In July 2002, tegaserod (Zelnorm), a stimulator of 5-HT4, was approved for the short-term treatment of women with constipationpredominant IBS. Both drugs are only indicated for women because they weren’t effective in men during clinical trials. Tegaserod has subsequently been approved for the treatment of chronic idiopathic constipation in both men and women under the age of 65 years. Antidepressants, anti-anxiety compounds and a variety of hormonal compounds also have been used to treat IBS.

A publication of the Duquesne University Mylan School of Pharmacy Pharmacy Care Awareness Program (PCAP) & Pharmaceutical Information Center (PIC) Additional information on any of the topics discussed may be obtained from the Pharmaceutical Information Center by calling 412-396-4600 or sending an e-mail to pic@duq.edu. Questions about screenings or programs: Christine O’Neil, Pharm.D, B.C.P.S. 412-396-6417 1/05 302828 cg


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