Resource Toolkit for the presentation, "A Patient-Centered Approach to Managing IBS-C and CIC"
Review of Treatment Options for Irritable Bowel Syndrome with Constipation and Chronic Idiopathic Constipation
Irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are two common disorders of gut–brain interaction. Affected patients often first present to their primary care providers seeking care for symptoms of constipation, abdominal pain, and bloating, which have a significant impact on their health-related quality of life. These patients often require extensive counseling and reassurance, and knowledge of reliable diagnostic criteria and treatment options is imperative to managing their conditions.
Family medicine practitioners, including nurse practitioners and physician assistants, are uniquely qualified to provide a diagnosis and safe, effective management of these disorders. This article reviews the latest evidence and provides practical advice related to diagnosis and management of IBS-C and CIC.
Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study
Although functional gastrointestinal disorders (FGIDs), now called disorders of gut-brain interaction, have major economic effects on health care systems and adversely affect quality of life, little is known about their global prevalence and distribution. Data were collected via the Internet in 24 countries, personal interviews in 7 countries, and both in 2 countries, using the Rome IV diagnostic questionnaire, Rome III irritable bowel syndrome questions, and 80 items to identify variables associated with FGIDs. This large-scale, international study found that more than 40% of persons worldwide have FGIDs, which affect quality of life and health care use.
Burden of Constipation: Looking Beyond Bowel Movements
Chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) are associated with significant social and economic burdens. To address these burdens, a deeper understanding of their root causes is required. A discrepancy exists between patients' and healthcare providers' (HCPs) perceptions of constipation symptoms and the impact of symptoms associated with CIC and IBS-C. Noting that significant sex and cultural differences exist regarding individuals consulting their HCP about constipation, the authors show that many individuals with CIC and IBS-C remain inadequately managed and unduly affected, contributing to the high social and economic burden of these conditions.
Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based medicine
The complexity and diversity of IBS presentation makes treatment difficult. Although there are reviews and guidelines for treating IBS, they focus on the efficacy of medications for IBS symptoms using high-priority endpoints, leaving those of lower priority largely unreported. Therefore, the aim of this review published in the World Journal of Gastroenterology is to provide a comprehensive evidence-based review of the diagnosis, pathogenesis and treatment to guide clinicians diagnosing and treating their patients.
Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management
Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age. Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy. This article further explores options for those patients who are not responding to lifestyle-based treatments or laxatives, including pharmacological and surgical intervention.
A case-control comparison of direct healthcare-provider medical costs of chronic idiopathic constipation and irritable bowel syndrome with constipation in a community-based cohort
Patients with constipation account for 3.1 million US physician visits a year, but care costs for patients with irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) compared to the general public have received little study. The study aim was to describe healthcare utilization and compare medical costs for patients with IBS-C or CIC vs matched controls from a community-based sample. Using REP healthcare utilization data, unadjusted and adjusted standardized costs were compared for the 2- and 10-year periods prior to the survey for 115 IBS-C patients and 230 controls and 365 CIC patients and 730 controls. The research shows that patients with IBS-C and CIC had significantly higher outpatient costs for the 2-year period compared with controls. IBS-C patients also had higher ER costs than the general population.
The Better Understanding and Recognition of the Disconnects, Experiences, and Needs of Patients with Chronic Idiopathic Constipation (BURDEN-CIC) Study
There is limited literature comparing the experiences and attitudes of patients with chronic idiopathic constipation (CIC) to those of healthcare professionals (HCPs) treating CIC patients. The BURDEN-CIC study was conducted to better understand the experiences and ongoing needs of CIC patients and to assess their alignment versus disconnection with the perceptions and needs of HCPs who treat CIC patients.
The survey identified that many patients are “accepting” of their disease, potentially compromising treatment outcomes. More dialogue is needed between HCPs and CIC patients, especially regarding management of treatment expectations and side effects.
Comorbidities in Patients With Irritable Bowel Syndrome With Constipation or Chronic Idiopathic Constipation
Irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are common functional bowel disorders. Patients with IBS-C or CIC often present with ≥ 1 comorbidity that coincides with either of these conditions. These comorbidities may make underappreciated contributions to the patient's overall disease burden. A total of 70 distinct comorbidities were identified from 35 published studies. These comorbidities involved several body systems, including the gastrointestinal, genitourinary, psychiatric, endocrine, and allergic or immunologic systems. The investigators therefore believe that medical professionals should consider common comorbidities when diagnosing and treating patients with IBS-C or CIC.
Chronic Constipation in the United States: Results From a Population-Based Survey Assessing Healthcare Seeking and Use of Pharmacotherapy
Chronic idiopathic constipation (CIC) is characterized by unsatisfactory defecation and difficult or infrequent stools. CIC affects 9%–20% of adults in the United States, and although prevalent, gaps in knowledge remain regarding CIC healthcare seeking and medication use in the community. Researchers found that 3 of 5 Americans with constipation have never discussed their symptoms with a healthcare provider. Furthermore, the use of prescription medications for managing constipation symptoms is low because individuals mainly rely on over-the-counter therapies.
Effective Communication Strategies and Tools for Improving Treatment Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation
Given the subjective nature of these disorders, patient self-reporting is critical to diagnosis and monitoring response to therapy. Unfortunately, many patients are reluctant to discuss bowel symptoms with their healthcare providers. Effective management of CIC and IBS-C requires an understanding of the patient's experience, a positive practitioner–patient relationship, realistic and agreed-upon treatment goals, and standardized monitoring of treatment response. There are multiple symptom and quality-of-life scales available to assist healthcare providers in this endeavor discussed here, along with methods for engaging patients.
Bowel Disorders
Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, sex, race, creed, color, or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical, as they impose a negative economic impact to the global health care system in addition to reducing quality of life.
This article classifies the FBDs into 5 distinct categories: irritable bowel syndrome, functional constipation, functional diarrhea, functional abdominal bloating/distention, and unspecified FBD. Also included in this article is a new sixth category, opioid-induced constipation, which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features, and treatment.
Understanding and Managing IBS and CIC in the Primary Care Setting
Irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) are highly prevalent chronic functional gastrointestinal (GI) disorders that are among the most common conditions seen by gastroenterologists and primary care providers. Recent data suggest that many diagnoses of IBS are made by generalists, and approximately 40% of patients with IBS-D are treated by their primary care physicians. To that end, the confidence of primary care providers to diagnose IBS/CIC accurately and utilize evidence-based treatments is important in managing these chronic and costly disorders.
Real-World Treatment Strategies to Improve Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation
Chronic idiopathic constipation and irritable bowel syndrome with constipation are complex, overlapping conditions. Although multiple guidelines have informed healthcare providers on appropriate treatment options for patients with chronic idiopathic constipation and irritable bowel syndrome with constipation, little direction is offered on treatment selection. Given the broad spectrum of available agents, therapy should be tailored by mutual decision-making between the patient and practitioner, with patients actively monitored and managed to maximize clinical outcomes.
Comorbidities in Patients With Irritable Bowel Syndrome With Constipation or Chronic Idiopathic Constipation: A Review of the Literature From the Past Decade
A total of 70 distinct comorbidities were identified from 35 published studies. These comorbidities involved several body systems, including the gastrointestinal, genitourinary, psychiatric, endocrine, and allergic or immunologic systems. Functional dyspepsia and depression were the most common comorbidities in patients with IBS-C, whereas functional dyspepsia, diabetes, and depression were the most common comorbidities in patients with CIC. The authors therefore believe that medical professionals should consider common comorbidities when diagnosing and treating patients with IBS-C or CIC.
Treatment Algorithm for Chronic Idiopathic Constipation and Constipation-Predominant Irritable Bowel Syndrome Derived from a Canadian National Survey and Needs Assessment on Choices of Therapeutic Agents
Chronic idiopathic constipation (CIC) and constipation-predominant irritable bowel syndrome (IBS-C) are common functional lower gastrointestinal disorders that impair patients' quality of life. In a national survey, the authors aimed to evaluate (1) Canadian physician practice patterns in the utilization of therapeutic agents listed in the new ACG and AGA guidelines; (2) physicians satisfaction with these agents for their CIC and IBS-C patients; and (3) the usefulness of these new guidelines in their clinical practice.
Low FODMAP Diet: Evidence, Doubts, and Hopes
Food is often considered to be a precipitating factor of irritable bowel syndrome (IBS) symptoms. In recent years, there has been a growing interest in FODMAPs (Fermentable Oligo-, Di-, Mono-saccharides, And Polyols), which can be found in many common foods. A low FODMAP diet (LFD) is increasingly suggested for IBS treatment.
However, long-term, large, randomized controlled studies are still lacking, and certainties and doubts regarding LFDs have grown, often in a disorderly and confused manner. The aim of the present review is to clarify the effective and appropriate indications and limitations of an LFD and to discuss its possible future uses.
How to institute the low-FODMAP diet
Randomized controlled trials have raised the profile of the low-FODMAP diet to become a viable first-line therapy for IBS, when implemented under a dietitian's guidance. Importantly, the diagnosis of IBS should be confirmed before commencement of the dietary approach. If a strict low-FODMAP diet is deemed necessary, it should only be for an initial period of 4 to 6 weeks. Research suggests that a strict long-term, low-FODMAP diet may negatively impact intestinal microbiome. After the initial strict period, follow up with the dietitian should be conducted to achieve the overall goal—a relaxed FODMAP restriction that enables inclusion of prebiotic FODMAPs while still maintaining symptom relief.
American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation
Given its prevalence, the frequency of symptoms, and their associated debility for many patients and the fact that IBS typically occurs in younger adulthood, an important period for furthering education, embarking on careers, and/or raising families, the socioeconomic impact of IBS is considerable. These indirect medical costs are frequently compounded by the direct medical costs related to additional medical tests and the use of various medical and nonmedical remedies that may have limited impact.
How Effective Are Secretagogues for Irritable Bowel Syndrome With Constipation
All secretagogues showed significant efficacy in high-quality controlled trials comparing these agents with placebo, in line with regulatory requirements. Because they provide clinicians with several effective therapeutic options, the question arises of how to select the agent with the best chance of a favorable clinical outcome. However, no head-to-head comparisons have been conducted. Network meta-analysis (NMA) or multiple treatments comparison meta-analysis allows to overcome this limitation
Mechanisms of Action of Current Pharmacologic Options for the Treatment of Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation
Multiple therapeutic agents are currently available for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation. A better understanding of the mechanism of action of each treatment provides important insights into expected responses and is key to optimizing treatment outcomes. Some constipation treatments, such as stimulant laxatives, may increase bowel movement frequency but are ineffective at relieving, and may even exacerbate, abdominal symptoms.
This review summarizes the mechanisms of action of commonly used over-the-counter and prescription therapies for chronic idiopathic constipation and irritable bowel syndrome with constipation, outlining how these mechanisms contribute to the efficacy and safety of each treatment option.
Medical Treatment of Constipation
Various agents are used for the medical management of chronic constipation, but few of these have been adequately studied. This article specifically examines the medical treatment of chronic constipation and the available data concerning bulk agents, lubricating agents, stimulants, and osmotic laxatives, used alone and in combination.
Secretagogues in Patients With Irritable Bowel Syndrome With Constipation: Systematic Review and Network Meta-analysis
We identified 15 eligible randomized controlled trials of secretagogues that included 8462 patients. Linaclotide, lubiprostone, plecanatide, and tenapanor were superior to placebo for the treatment of IBS-C. Linaclotide (290 μg once daily) was ranked first in efficacy based on the end point recommended by the Food and Drug Administration for trials in IBS-C, the primary end point used in each trial, abdominal pain, and complete spontaneous bowel movements.
Novel Treatments from Inhibition of the Intestinal Sodium-Hydrogen Exchanger 3
While there are nine isoforms of NHE in humans, this review focuses on the NHE3 isoform, which is abundantly expressed in the gastrointestinal tract, where it plays a key role in acid–base balance and water homeostasis. NHE3 inhibition in the small intestine results in luminal sodium and water retention, leading to a general decrease in paracellular water flux and diffusional driving force, reduced intestinal sodium absorption, and increased stool sodium excretion. The resulting softer and more frequent stools are the rationale for the development of tenapanor as a novel, first-in-class NHE3 inhibitor to treat irritable bowel syndrome with constipation.
Current developments in pharmacological therapeutics for chronic constipation
Chronic constipation is a common gastrointestinal disease severely affecting the patient’s quality of life. The traditional treatment of constipation is the use of laxatives. However, a significant unmet medical need still remains, particularly among those patients achieving poor results by current therapies. This article provides a comprehensive review on the pharmacological therapeutics for the treatment of chronic constipation, with the purpose of reflecting the drug development trends in this field.
The Bristol Stool Scale
The Bristol Stool Scale is a way to talk about shapes and types of bowel movements. The chart is designed to help measure the time it takes for food to pass through bodies and leave as waste. The shape and form of bowel movements may also point toward a diagnosis of some digestive problems. You can find a chart and more information here.
Get your CME credit for watching the video!
Don't forget to fill out the survey, including your email address, if you would like to receive CME credit for watching the video above. In addition to the 1.0 AAFP Prescribed Credit, an additional 2.0 AAFP t2p® (Translation to Practice®) credits will also be offered to those learners who wish it. In addition to letting us know in the survey link that you'd like to receive the additional t2p® credits, you'll need to participate in a follow-up survey to talk about the changes you've made as a result of the presentation.
So start here, and keep going!