Supporting and treating people with IBS


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13 Apr 2017

Community pharmacy can offer support and advice for people with this debilitating long-term disorder, writes Ewa Gabzdyl

Learning points

  • IBS affects around 15-20% of the UK population at any one time
  • Pharmacists need to be aware of the ‘red flag’ signs such as rectal bleeding and know when to refer
  • A food diary can help show any patterns where symptoms may be worse
  • It’s a good idea to assess the physical activity levels of a patients with IBS symptoms

Estimated to affect around 15-20% of the UK population at any one time – IBS causes a significant burden on the NHS, with a total attributable cost of almost £12 million per annum (2012–2013).[2]

Defined as a chronic, debilitating and often lifelong disorder of gastrointestinal function with no discernible structural or biochemical cause,[1] irritable bowel syndrome (IBS) can cause significant pain and disruption to many people’s lives.

Through more in-depth understanding of the nature and causes of IBS, pharmacists can facilitate self-management of the condition.

Knowing it’s IBS

IBS is a long-standing illness consisting of frequent abdominal discomfort and bowel symptoms that cannot be explained by any other disease. Symptoms can be complex and conflicting and can include one or a combination of constipation, diarrhoea, abdominal cramps and pain, bloating, changes in bowel movement and frustrated defaecation. Other common symptoms that may be associated with IBS can be:

•Tiredness.

•Nausea.

•Heartburn and indigestion.

•Backache.

•Needing to pass urine frequently.

•Headaches, muscle pain.

•Anxiety and depression.

Making a diagnosis

Initially, the pharmacist will need to understand how long the person has experienced symptoms, family history, lifestyle, physical exercise regimes, dietary habits, and ask about any impact of stressful situations on their symptoms. It’s important to know about bowel habits and look out for symptoms of IBS. For example, unresolved diarrhoea, constipation, straining, urgency, incomplete evacuation, passage of mucus, abdominal pain and discomfort, bloating (more common in women), distension, tension or hardness.

‘Red flag’ indicators (see box 1) may help to screen more worrying conditions, such as cancer. Where any of these symptoms are present, it is essential that the person is referred to their GP straight away.

Many people with IBS can feel stigmatised and uncomfortable talking about their symptoms within the pharmacy setting. Offering the option to discuss their symptoms in a private consultation room is essential to provide a more relaxed environment for them to ask open questions without fear of embarrassment.

Medication 

There is a wide variety of GSL, P and POM treatments available to relieve the many different symptoms of IBS. Drug treatments should be recommended or prescribed according to the predominant symptoms, and in some cases a combination of treatment may be required.

However, it’s important to note that:

•There is no cure for IBS.

•There is no single drug that effectively treats all the symptoms of IBS.

•Some drugs may treat some symptoms but make others worse. For example treatments for diarrhoea can cause constipation and make pain and bloating worse.

•People with a sensitive gut often experience side-effects from drugs.

•Most drugs used to treat the symptoms of IBS can be bought OTC.

•The placebo effect is very powerful in people with IBS.

•Drugs currently available can be useful in certain situations but should not be used indefinitely.

•Since each patient with IBS is an individual with different symptoms, the treatment will vary from case to case.

•In many people, listening and reassurance, simple dietary manipulations, lifestyle changes, relaxation techniques, cognitive behavioural therapy or hypnotherapy may have a better outcome than drug therapy.

•People with IBS may need to work closely with their pharmacist or GP to find the treatments and doses that are right for them.

OTC medicines for constipation or diarrhoea

To treat constipation symptoms related to IBS, bulking agents, osmotic laxatives, purgative and stimulants may be used.

For diarrhoea symptoms, the most effective opiate-like antidiarrhoeals are related to morphine, but not addictive and act mainly on the gut. These include:

•Loperamide (Imodium) – the most powerful and with the fewest side-effects.

•Diphenoxylate (Lomotil) – also contains a bowel relaxant that can cause a dry mouth.

•Codeine phosphate – can result in drowsiness.

If diarrhoea alternates with constipation, doctors tend to treat it with a bulking agent such as psyllium or ispaghula husk, which firms up the stool and induces a more regular bowel action.

OTC treatments for abdominal pain, bloating and flatulence

Antispasmodic drugs reduce the force of intestinal contraction and are used to ease spasm and alleviate pain. Some people find that antispasmodics can help to relieve symptoms of bloating and distension.

According to the NICE guidelines,[3] laxatives should be considered for the treatment of constipation in people with IBS, but they should be discouraged from taking lactulose. It also states that healthcare professionals should discourage the use of aloe vera in the treatment of IBS.

Food

People with IBS usually find that eating can trigger their symptoms, but it’s often difficult to identify what component, if any, of the meal may be responsible.

For others, certain food and drink may exacerbate their symptoms. The British Dietetic Association food factsheet outlines recommendations on eating habits and diet to help reduce IBS symptoms.[4]

In around 70% of people with IBS,[5] a low FODMAP diet has shown a reduction in symptoms. FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are a collection of poorly absorbed simple and complex sugars found in a variety of fruits and vegetables, milk and wheat. FODMAPs don’t cause IBS but they can trigger symptoms of IBS in a sensitive gut. It is recommended that anyone following this diet sees a registered dietitian.

A food diary will help show any patterns where symptoms may be worse. If people are struggling to make changes or are losing weight as a result of dietary restrictions, they should be referred to a dietitian or GP.

Lifestyle

In many cases, pharmacists will need to assess the physical activity levels of the person with IBS symptoms.

Providing advice on managing stress and anxiety, whether through adapting the work/life balance, counselling and psychotherapy services can be useful. Pain that is resistant to antispasmodics may respond to low doses of antidepressants. This may be partly due to the alleviation of an underlying depression and partly because of a direct effect on pain pathways in the gut. Anxiety and depression can make people more sensitive to pain and can upset the bowels.

IBS is a complex, long-standing illness that is often difficult to diagnose. Through a better understanding of the potential triggers, pharmacists can support people with IBS and encourage self-management.

‘Red flag’ symptoms

The following symptoms are warning signs for a person to be referred to their GP:

•Rectal bleeding. This should never be ignored. Regular loss of blood from the rectum could be a symptom of colitis or cancer

•Unintentional or unexplained weight loss. If more than half a stone (3kg) weight is lost without trying, this should be checked with a GP

•Persistent fever and malaise (attacks of sweating, shivering and tiredness)

•An ongoing change in bowel habit to looser and / or frequent stools persisting for more than six weeks, occurring for no obvious reason (ie diet, stress or medication).

•Family history of bowel or ovarian cancer

•Anaemia

References

1 NICE guidelines, https://cks.nice.org.uk/irritable-bowel-syndrome#!diagnosissub:2/-494656

2 Williams M, et al. Frontline Gastroenterology 2016;0:1–8. doi:10.1136/flgastro-2016-100727

3 NICE CG 61, February 2015,

https://www.nice.org.uk/guidance/cg61/resources/irritable-bowel-syndrome-in-adults-diagnosis-and-management-975562917829

4 NICE CG 61, February 2015,

https://www.nice.org.uk/guidance/cg61/resources/irritable-bowel-syndrome-in-adults-diagnosis-and-management-975562917829

5 https://www.bda.uk.com/foodfacts/IBSfoodfacts.pdf

6 Marsh A, Eslick EM, Eslick GD (2015). ‘Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis’. Eur J Nutr. doi:10.1007/s00394-015-0922-1. PMID 25982757


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