April is IBS month

Irritable bowel syndrome (IBS)
Stan Nikitin, PharmD Candidate 2011

April is IBS month, and you may be wondering “what exactly is IBS?” IBS stands for irritable bowel syndrome, which is a disorder affecting the large intestine, also called the colon.  It's one of the most commonly diagnosed gastrointestinal conditions, affecting 55 million Americans.  This means about 1 in 6 people have symptoms of IBS!  Women tend to be affected more often than men. The exact cause of IBS is unknown. There are many hypotheses and the causes may include genetics, problems with the intestinal muscles, infections, stress or other psychological factors.^1-3

Symptoms of IBS
The symptoms of IBS usually begin in adolescence or early adulthood, but can occur at any age.  Symptoms can vary in severity, but the good news is that most people with IBS have mild symptoms. Abdominal pain, fullness, flatulence (gas), and bloating that have been present for at least 6 months are the main symptoms of IBS.²  While different people are affected differently, the symptoms can also include:

·       Cramping - pain or tightness in the abdomen

·       Changes in bowel movements

·       Constipation or diarrhea - both can occur, but mostly it is one or the other

·       Mucus in the stool⁴

Symptoms are more likely to occur after meals, can come and go, and may be milder or disappear completely following a bowel movement.

All people are affected differently. For most people IBS is a chronic condition, but symptoms can come and go, improve or worsen, and be present constantly or intermittently.

The symptoms of IBS may seem daunting and scary, but fortunately, do not cause any permanent damage to the colon. For example, IBS does not increase the risk for colorectal cancer. Also, IBS does not cause any inflammation or changes in bowel tissue unlike the more serious intestinal diseases such as Crohn’s disease or ulcerative colitis.⁴


Diagnosis
IBS is largely diagnosed based on symptoms.  Your doctor will diagnose IBS based on your symptoms, medical history, and a physical exam.  If any tests are necessary, they are to rule out any other conditions.  The tests may be necessary especially if there is weight loss, rectal bleeding, fever, nausea or recurrent vomiting, abdominal pain that is not completely relieved by a bowel movement, diarrhea that is persistent or awakens you from sleep, or if symptom onset occurs after the age of 50.  Some of the tests can include:⁴

·       Blood tests - check for blood loss or deficiency, inflammation, and Celiac disease (symptoms of which may resemble IBS)

·       Stool analysis - checks for blood in the stool and certain infections (for example, parasites).

·       Sigmoidoscopy or colonoscopy - allows the doctor to look inside the intestine for abnormal growths, bleeding, inflammation, and other irregularities

·       Lactose intolerance test - tests for lactase deficiency. Some people lack the enzyme lactase, which breaks down dairy sugars. Affected people may have symptoms resembling IBS after eating or drinking dairy products. Your doctor may instruct you to avoid dairy products for several weeks to rule out lactase deficiency.

Treatment
While IBS is a chronic condition, it is manageable. The focus of treatment is to relieve symptoms. Diet and lifestyle changes can help you manage IBS. More severe forms of IBS may require the use of medications that can help alleviate symptoms.


Diet and Lifestyle Changes
Making changes to your diet and lifestyle may help relieve IBS symptoms.

Lifestyle changes:

·       Exercise - exercise may reduce anxiety and stress, which in turn may help relieve IBS symptoms.

·       Improved sleep habits – an erratic sleep schedule may worsen IBS symptoms. Improving your sleep habits may help. Try to go to bed at the same time each day and get plenty of sleep to avoid fatigue and potential stress.

Dietary changes:

·       Eat at regular times - try to eat at the same time each day. Do not skip meals. Avoid large meals.

·       Avoid problem foods - avoid foods that you know for certain trigger your IBS symptoms. Avoid fatty foods or ones with high sugar content. Artificial sweeteners (such as sorbitol and mannitol) may be found in sugar-free gum or other foods and can be problematic. Certain foods and drinks stimulate the intestines. Caffeine containing products (coffee, tea, and energy drinks) are notorious for this effect. Carbonated drinks like soda can produce gas. Some other problem foods may include whole grains, chocolate, or alcohol. Vegetables like broccoli, cauliflower, cabbage, and beans can increase gas. Dairy products may cause much discomfort to lactose intolerant people. See lactose intolerance test above.^1,2,4

·       Foods rich in fiber - while fiber-rich foods such as fruits, vegetables, and beans may help with constipation for some people, they can make symptoms worse for others.

·       Drink plenty of water - water is always best. Remember that coffee, tea, alcohol, soda, and dairy products like milk can worsen the symptoms.

Medication
Medication use in IBS should target your most upsetting symptoms. The lowest dose possible that relieves your symptoms is usually recommended. If you are considering using over-the-counter medication, discuss such use with your doctor or pharmacist before selecting one. Explaining your symptoms to your doctor or pharmacist can help the healthcare professional recommend the right medication for you.

Over-the-counter (OTC) medications

·       Immodium (loperamide) - loperamide decreases the frequency of bowel movements, which may be of relief to some with diarrhea, but it does not help with other IBS symptoms.

·       Fiber supplements - fiber supplements such as Metamucil may help with constipation- predominant IBS, but can make symptoms worse for people with diarrhea-predominant IBS.

·       Laxatives - there are various laxative types that work in different ways to help with constipation.  Discuss with your doctor or pharmacist which laxative may be appropriate for you.

Prescription medications

Diarrhea-Predominant IBS:

·       Antispasmodic drugs may help with intestinal spasms and cramping.^2-5 These drugs relax the smooth muscles of the intestine using an anticholinergic mechanism. Some examples of these medications are hyoscyamine and dicyclomine.  Common side effects are drowsiness, dry mouth, blurred vision, constipation, and urinary retention.⁶

·       Cholestyramine may be helpful to people with bile acid absorption problems.^1,3  The most common side effect reported with cholestyramine use is constipation.⁶

·       Lotronex (alosetron) is approved for women only with diarrhea-predominant IBS and has restricted use. It can only be prescribed by a doctor enrolled in a special program.^1,4,5  The most common side effect reported is constipation.⁶

Constipation Predominant IBS:

·       Amitiza (lubiprostone) is approved for women 18 and older only who have constipation predominant IBS. ^{4, 5} Common side effects are nausea, headache, and diarrhea.⁶

Other therapies:

·       Xifaxan (rifaximin) is an oral non-absorbable (acts in the gastrointestinal tract without getting into the bloodstream) antibiotic that may be effective for global IBS symptoms, especially for diarrhea-predominant IBS. ⁷ This drug is minimally absorbed and stays in the intestine. Common side effects are flatulence (gas), nausea, dizziness, and fatigue.⁶

·       For difficult to treat conditions your doctor may prescribe antidepressants. These can include 2 drug classes: tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). These can be helpful in relieving abdominal pain and slowing down intestinal transit time.^1,2,4,5 Common side effects with TCAs are drowsiness, dry mouth, blurred vision, constipation, urinary retention, and weight gain.⁶  Common side effects with SSRIs are headache, sleepiness, insomnia, nausea, diarrhea, and sexual dysfunction.⁶

·       Other treatment options exist such as probiotics, peppermint oil, herbal therapies and acupuncture. While these treatments may be helpful and beneficial to some, there’s little medical evidence about their effectiveness.

What to expect
Irritable bowel syndrome can be a chronic, lifelong condition and has no known cure. Many people with IBS learn to manage the condition and still lead active, fruitful lives. Understandably, the condition may not be easy to discuss, but be open about your communication with healthcare professionals. Be informed, ask lots of questions, and remember that healthcare professionals are there to help! Be your own advocate and take charge in the management of your IBS!

For more information:

·       Mayo Clinic
http://www.mayoclinic.com/health/irritable-bowel-syndrome/DS00106

·       WebMD
http://www.webmd.com/ibs/default.htm

·       WebMD Support Group Message Board
http://exchanges.webmd.com/ibs-support-group

·       National Institutes of Health
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001292

·       U.S. National Library of Medicine Interactive Tutorial http://www.nlm.nih.gov/medlineplus/tutorials/irritablebowelsyndrome/htm/index.htm

·       National Digestive Diseases Information Clearinghouse
http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/

·       American College of Gastroenterology
http://www.acg.gi.org/patients/ibsrelief/index.asp

References
1. Spruill WJ, Wade WE. Diarrhea, constipation, and irritable bowel syndrome. In: DiPiro JT, Talbert RL, Yee G, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill; 2008:628-631.

2. U.S. National Library of Medicine, National Institutes of Health. Irritable bowel syndrome. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001292. Updated July 7, 2010. Accessed February 24, 2011.

3. WebMD. Irritable bowel syndrome health center. http://www.webmd.com/ibs/default.htm. Updated May 23, 2008. Accessed February 24, 2011.

4. Mayo Clinic. Irritable bowel syndrome. http://www.mayoclinic.com/health/irritable-bowel-syndrome/DS00106. Updated July 29, 2009. Accessed February 24, 2011.

5. Wald, A. Treatment of irritable bowel syndrome. In: UpToDate, Talley NJ (Ed), UpToDate, Waltham, MA, 2011. Accessed February 24, 2011.

6. Wickersham RM, ed. Drug Facts and Comparisons. St. Louis, MO: Wolters Kluwer Health; 2011. http://online.factsandcomparisons.com. Accessed March 2, 2011.

7. American College of Gastroenterology. ACG releases evidence-based systematic review on management of irritable bowel syndrome. http://www.acg.gi.org/media/releases/december182008.asp. Published December 18, 2008. Accessed March 14, 2011.

Raising Diabetes Awareness

By: Amanda Hodges, PharmD Candidate 2012

University of Illinois at Chicago College of Pharmacy

November is American Diabetes Month. Currently in the U.S., 23.6 million, or 7.8% of the population have diabetes and approximately 5.7 million people do not know they have the disease. Diabetes has become the seventh leading cause of death in the U.S. There are 2 forms of diabetes, Type 1, previously known as juvenile diabetes, and Type 2, which is more common. Patients with Type 2 diabetes either do not produce enough insulin or the cells ignore the insulin. Insulin is a hormone that is released from the pancreas and its release is necessary for the body to be able to use glucose or energy. When food is ingested, the body breaks down sugars and starches into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into cells, it can lead to a numerous symptoms and diabetic complications. Some symptoms include increased thirst, frequent urination, increased hunger, weight loss, fatigue, and blurred vision. Some long-term complications include heart disease, stroke, kidney disease, nerve damage, eye problems, and amputations.

A variety of risk factors increase the likelihood that a patient will develop Type 2 diabetes. Some of these risk factors include:

• Age - people over 45 years are at higher risk
• People with a family history of diabetes
• People who are overweight
• People who do not exercise regularly
• Certain ethnic groups such as Non-Hispanic Blacks, Hispanic/Latino Americans, Asian Americans, and American Indians
• Women who had gestational diabetes while pregnant or women who had a baby weighing 9 pounds or more at birth

The goal of diabetes treatment is to control blood glucose levels, reduce long-term complications, and maintain a good quality of life. The first step in managing diabetes is for patients to modify their lifestyle by adjusting and maintaining a proper diet and exercising regularly. A nutrition plan that involves monitoring carbohydrate intake by carbohydrate counting or exchanges is recommended. In addition, patients should consume a diet high in dietary fiber/whole grains, fruit and vegetables, and low in saturated fats. For physical activity, 150 minutes per week of moderate-intensity aerobic exercise and resistance exercise 3 times per week to target all muscle groups is recommended; however, patients who have not exercised in the past should receive clearance from their physician and start slow with their exercise routine.

If a patient’s diabetes is not controlled by diet and exercise, he/she may be started on medications; however, it is important to continue to follow an exercise and diet plan to maximize the effect of prescribed treatments. A variety of oral and injectable treatments for diabetes are available including: metformin, sulfonylureas (e.g., glyburide, glipizide), thiazolidinediones (e.g., pioglitazone), alpha-glucosidase inhibitors (e.g., acarbose), insulin secretagogues (e.g, repaglinide), dipeptidyl peptidase-4 (DPP-4) inhibitors (e.g., sitagliptin), and insulin. The healthcare provider will decide what the best medication or combination of medications is needed. He or she should discuss proper dosing, administration, and common adverse reactions with the patient. One serious reaction to be aware of is low blood glucose, known as hypoglycemia, which can occur with some prescribed therapies. Symptoms of hypoglycemia include sweating, shakiness, weakness, hunger, dizziness, heart palpitations, blurred vision, and confusion.

Depending on the treatment plan the healthcare provider initiates, patients will most likely be monitoring blood glucose levels at home. It is important to know how often blood glucose levels should be checked at home, the range of acceptable values, and the specific factors that may impact blood glucose levels. For example, blood glucose readings may change in response to food intake, physical activity, medication administration times, acute illnesses, alcohol intake, and stress.

Careful monitoring of blood glucose is necessary to prevent long-term complications. In addition, other monitoring such as routine physical examinations, eye and foot examinations, blood tests to assess long-term markers of glucose control, cholesterol levels, and kidney function, and dental care can help minimize complications.

Amanda Hodges, PharmD Candidate 2012

Additional information about diabetes can be accessed at:

www.diabetes.org

www.cdc.gov/diabetes/consumer/

www.ndep.nih.gov/index.aspx?redirect=true