Symptoms in the Pharmacy :Gastrointestinal Tract Problems(17)
Irritable bowel syndrome
Treatment timescale
Symptoms should start to improve within 1 week.
Management
Antispasmodics
Antispasmodics are the mainstay of OTC treatment of IBS and research
trials show consistent improvement in abdominal pain with smooth
muscle relaxants.
Alverine citrate, peppermint and mebeverine are
used. They work by a direct effect on the smooth muscle of the gut,
causing relaxation and thus reducing abdominal pain. The patient
should see an improvement within a few days of starting treatment
and should be asked to return to you in 1 week so you can monitor
progress. It is worth trying a different antispasmodic if the first has not
worked. Side-effects from antispasmodics are rare.
All antispasmodics are contraindicated in paralytic ileus, a serious
condition that fortunately occurs only rarely (e.g. after abdominal
operations and in peritonitis). Here the gut is not functioning and is
obstructed. The symptoms would be severe pain, no bowel movements
and possibly vomiting of partly digested food. Immediate referral
is needed.
Alverine citrate
Alverine citrate is given in a dose of 60–120mg (one or two capsules)
up to three times a day. Remind the patient to take the capsules with
water and not to chew them. Side-effects are rare but nausea, dizziness,
pruritus, rash and headache have occasionally been reported.
The drug should not be recommended for pregnant or breastfeeding
women or for children. Alverine citrate is also available in a combination
product with sterculia (see ‘Bulking agents’, below).
Peppermint oil
Peppermint oil has been used for many years as an aid to digestion and
has an antispasmodic effect. Capsules containing 0.2 ml of the oil are
taken in a dose of one or two capsules three times a day, 15–30 min
before meals. They are enteric-coated with the intention that the
peppermint oil is delivered beyond the stomach and upper small
bowel. Patients should be reminded not to chew the capsules as not
only will this render the treatment ineffective, it will also cause irritation
of the mouth and oesophagus.
This treatment should not be recommended for children. Occasionally
peppermint oil causes heartburn and so is best avoided in patients
who already suffer from this problem. Allergic reactions can occur
and are rare; rash, headache and muscle tremor have been reported in
such cases. One trial involving 110 people showed improvement in
symptoms of abdominal pain, distension and stool frequency.
Mebeverine hydrochloride
Mebeverine hydrochloride is used at a dose of 135 mg three times a
day. The dose should be taken 20 min before meals. The drug should
not be recommended for pregnant or breastfeeding women, for children
under 10 or for patients with porphyria.
Bulking agents
Traditionally, patients with IBS were told to eat a diet high in fibre,
and raw wheat bran
was often recommended as a way of increasingthe fibre intake. Bran is no longer recommended in IBS .
Bulking agents such as ispaghula containing soluble
fibre can help some patients. It may take a few weeks of experimentation
to find the dose that suits the individual patient. Remind the
patient to increase fluid intake to take account of the additional fibre.
Bulking agents are also available in combination with antispasmodics.
The evidence for benefit is not strong, as studies have involved small
numbers of patients. Possible positive benefit has been shown for
ispaghula husk.
Antidiarrhoeals
Patients who complain of diarrhoea may be describing a frequent
urge to pass stools, but the stools may be loose and formed
rather than watery. Use of OTC antidiarrhoeals such as loperamide
is appropriate only on an occasional, short-term basis. In two studies
involving a total of 100 patients, loperamide improved diarrhoea,
including frequency of bowel movements, but not abdominal pain or
distension.
Practical points
Diet
Patients with IBS should follow the recommendations for a healthy
diet (low fat, low sugar, high fibre). Bran used to be widely recommended
but more recent research indicates that consumption of bran
(which contains insoluble fibre) is not helpful and can make symptoms
worse. Dietary sources of soluble fibre can be recommended including
oats and pulses.
Some patients find that excluding foods which they know exacerbate
their symptoms is helpful.
The sweeteners sorbitol and fructose can make symptoms worse and they
are found in many foods: the patients need to check labels at the
supermarket. Cutting out caffeine, milk and dairy products, and chocolate
may be worth trying. Although some patients benefit from the
withdrawal of milk and dairy products, there is no evidence of lactase
deficiency in IBS. Remind patients that caffeine is included in many
soft drinks and so they should check labels.
Complementary therapies
Some patients find relaxation techniques helpful. Videos and audio
tapes are available to teach complementary therapies.
Studies have shown that hypnotherapy is of benefit in IBS. If patients
want to try this, they should consult a registered hypnotherapist.
Others may benefit from traditional acupuncture, reflexology, aromatherapy
or homoeopathy.
Chinese herbal medicine
A recent high-quality randomised 16-week trial showed benefit
(global improvement) from standard and individualised Chinese
herbal treatment for IBS. The numbers needed to treat (NNTs) to
produce benefit were 2.3 for standard and 3.2 for individualised
treatment. The results were highly statistically significant. The herbal
medicine in this trial was prepared and dispensed by a herbal practitioner.
One of the difficulties in recommending this form of treatment
is the lack of control and consistency of the ingredients in herbal
preparations.
Irritable bowel syndrome in practice
Case 1
Joanna Mathers is a 29-year-old woman who asks to speak to the
pharmacist. She has seen an advertisement for an antispasmodic for
IBS and wonders whether she should try it. On questioning, she tells
you that she has been getting stomach pains and bowel symptoms for
several months, two or three times a month. She thinks her symptoms
seem to be associated with business lunches and dinners at important
meetings and include abdominal pain, a feeling of abdominal fullness,
diarrhoea, nausea and sometimes vomiting. In answer to your specific
question about morning symptoms, Joanna says that sometimes she
feels the need to go to the toilet first thing in the morning and may
have to go several times.
Sometimes she has been late for work
because she felt she couldn’t leave the house due to the diarrhoea.
Joanna tells you that she works as a marketing executive and that her
job is pressurised and stressful when there are big deadlines or client
meetings. Joanna drinks six or seven cups of coffee a day and says her
diet is ‘whatever I can get at work and something from the freezer
when I get home’. She is not taking any other medicines and has not
been to the doctor about her problems as she didn’t want to bother
him.
The pharmacist’s view
The picture that has emerged indicates IBS. She has the key symptoms
and there is a link to stress at work. It would be worth trying an
antispasmodic (alverine, peppermint oil or mebeverine) for 1 week
and asking Joanna to come back at the end of that time. She also needs
a careful explanation of aggravating factors for IBS and might want to
try a gradual reduction in her intake of coffee over the next few days.
If there is no improvement, a different antispasmodic could be tried
for a further week, with referral then if needed.
The doctor’s view
Joanna gives a clear history of IBS. Her symptoms are likely to settle
with the pharmacist’s advice and treatment. There is up to a 60%
placebo response rate in IBS sufferers, so it would be surprising if she
did not improve when next reviewed. If there were no improvement,
then a referral would be sensible. A referral would give her doctor an
opportunity to deal with her concerns about what was wrong and give
her an appropriate explanation of IBS. She could also be given some
time to consider how she might tackle her work pressures.
Case 2
Jane Dawson asks to see the pharmacist. She is in her early twenties
and says she has been getting some upper abdominal pain after food.
She wants to try a stomach medicine. On further questioning she says
that she has had an irritable bowel before but this is different, although
she does admit that her bowels have been troublesome recently
and she has noticed some urinary frequency. Jane says that she has
been constipated and felt bloated. She says that she went to her doctor
last year and was told she had IBS. The doctor said it was all due to
stress, which had upset her. Over the last year she has started a new
job and moved into new accommodation. She eats a healthy diet and
exercises regularly.
The pharmacist’s view
The history here is not straightforward and although Jane’s symptoms
are indicative of IBS, which she says she has had before, the symptoms
are different on this occasion. The best course of action is to refer her
to the doctor for further investigation.
The doctor’s view
Jane probably has IBS but there is insufficient information so far to
make that diagnosis. It is not uncommon to have upper abdominal
pain with IBS, but other possibilities need to be considered. It sounds
as though Jane thinks it is coming from her stomach. She may fear that
she has an ulcer. She also mentions urinary frequency, which may well
be associated with IBS but could be a urinary infection.
A referral to her doctor is sensible to make a complete assessment
of her symptoms. It is likely that the assessment would just involve listening to her
description of her problem, gathering more information and a brief
examination of her abdomen. A urine sample would show whether or
not she had a urinary infection. If there was still doubt about the
diagnosis, a referral to a gastroenterologist at the local hospital could
be made. Between 20% and 50% of referrals to gastroenterologists
turn out to be due to IBS. The main purpose of referral is for a
diagnosis as there is no therapeutic advantage.
If the doctor thinks Jane has IBS, an explanation of the syndrome
would be helpful in addition to dealing with her concerns about a
stomach ulcer. Whether or not psychological factors cause IBS there is
no doubt that the stresses of life can aggravate symptoms. It therefore
makes sense to help sufferers to make this connection so they can
consider different ways of dealing with stress.
Often the above approach is effective treatment in itself. However,
if Jane did want some medication, a bulk bowel regulator to help her
constipation plus some antispasmodic tablets would be of value.
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