DOCSLIB.ORG

Update on Pharmacotherapy for Irritable Bowel Syndrome

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Update on Pharmacotherapy for Irritable Bowel Syndrome Current Gastroenterology Reports (2019) 21: 25 https://doi.org/10.1007/s11894-019-0692-7 LARGE INTESTINE (B CASH AND S KHAN, SECTION EDITORS) Update on Pharmacotherapy for Irritable Bowel Syndrome Akhil Munjal1 & Bhavtosh Dedania2 & Brooks Cash2 Published online: 25 April 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Irritable bowel syndrome (IBS) is a functional GI disorder that affects a large percentage of the population and presents a significant socio-economic burden on the society. In this article, we reviewed the evidence supporting various pharmacological treatment options for IBS. Recent Findings Rifaximin, eluxadoline, and alosetron have demonstrated that they reduce symptom severity improving quality of life in patients with IBS–diarrhea. Ramosetron is a promising agent in development. Peppermint oil has also demonstrated a positive impact on some symptoms of IBS. For IBS with constipation, traditional laxatives have failed to demonstrate significant benefit. However, lubiprostone, linaclotide, and plecanatide have demonstrated improvement of IBS with constipation in large, placebo-controlled trials. Tenapanor, a sodium/hydrogen exchanger 3 inhibitor, appears to be a promising treatment option in the pipeline. Summary There are multiple pharmacologic agents with a variety of mechanisms that have demonstrated efficacy in IBS with diarrhea and constipation. There are no established pharmacologic agents for IBS with a mixed bowel pattern. There is a promising pipeline for additional novel therapies for IBS. Keywords Irritable bowel syndrome . Pharmacologic therapies . Diarrhea . Constipation Introduction and higher utilization of healthcare resources. Patients with severe IBS symptoms miss more days of work leading to Irritable bowel syndrome (IBS) is a chronic functional gastro- decreased productivity. Many patients undergo extensive intestinal (GI) disorder affecting a sizable percentage of the medical evaluation including endoscopic, laboratory, and ra- adult population, with a prevalence as high as 15% in Europe diologic tests that are often unrevealing as IBS has no reliable and North America [1]. IBS has an especially high prevalence biomarkers [2]. Multiple proposed theories and mechanisms in working-age adults and represents a significant socio- regarding the pathophysiology of IBS include altered GI mo- economic burden on patients and society. There is a significant tility, visceral hypersensitivity, alteration in the brain-gut axis, reduction in the quality of life of patients afflicted with IBS alteration of the gut microbiome, including food intolerances, post-infectious immune reactivity, and chronic intestinal in- This article is part of the Topical Collection on Large Intestine flammation. However, the exact etiology is still unclear and it is likely that there are multiple and inter-related factors lead- * Brooks Cash ing to IBS symptom generation [3]. Based on the Rome IV [email protected] criteria [4, 5], IBS is characterized by pain or discomfort as- Akhil Munjal sociated with altered bowel habits, including both constipation [email protected] and diarrhea, and can include postprandial urgency, abdomi- Bhavtosh Dedania nal bloating, or distention. Conventional therapies for many [email protected] years have consisted of anti-diarrheal and laxative medica- tions for bothersome bowel habits and anti-spasmodic or pain 1 Department of Internal Medicine, University of Texas Health Science medications for the sensory symptoms of IBS. This article will Center at Houston/McGovern Medical School, 6431 Fannin Street, focus on recent pharmacological advances in IBS Houston, TX 77030, USA pharmacotherapy. 2 Division of Gastroenterology, University of Texas Health Science IBS is broadly classified based on abnormal bowel habits Center at Houston/McGovern Medical School, 6431 Fannin Street, MSB 4.234, Houston, TX 77030, USA into four broad categories: IBS-D (predominantly diarrhea), 25 Page 2 of 7 Curr Gastroenterol Rep (2019) 21: 25 IBS-C (predominantly constipation), IBS-M (mixed pattern (incidence of 0.3% in pooled meta-analysis studies) [6]and including both diarrhea and constipation), and IBS-U (unclas- complications arising from constipation. The medication was sifiable within the three previously mentioned subtypes) [5]. withdrawn from the market in 2000 due to safety concerns; In addition, IBS is not static and patient symptoms can change however, due to its clinical utility in appropriately selected over time between different subtypes. An overview of phar- patients, it was made available again in 2002 under the aus- macologic therapies that are frequently used to treat the spec- pices of strict prescribing restrictions and a risk management trum of IBS as well as emerging pharmacologic therapies is program. In January 2016, the FDA removed the restrictive listed in Table 1. requirements of the risk evaluation and mitigation strategy (REMS) due to accumulated favorable safety data. The body of evidence demonstrating beneficial effects of alosetron is large. A randomized controlled trial by Cremonini Irritable Bowel Syndrome–Diarrhea et al. studied 705 women with IBS-D over a period of 12 weeks [7]. Subjects were randomized into various treat- Alosetron ment groups with different doses of alosetron vs placebo. This study showed a statistically significant improvement in Alosetron is a 5-HT3 receptor antagonist approved by the US quality of life in IBS-D patients who received one or more Food and Drug Administration (FDA) for treating IBS-D in doses of alosetron when compared with placebo, with the women refractory to “conventional” therapies. 5-HT3 recep- most common adverse effect being constipation. Treatment tor stimulation is associated with increased gastrointestinal with alosetron 0.5 mg daily and 1 mg BID decreased lost motility and secretion, and alosetron, being an antagonist, workplace productivity hours − 11.0 ± 3.3 and − 21.1 ± slows down fecal transit through the colon and provides more 4.1 h, p < 0.05, and lost social/leisure hours − 6.7 ± 0.8 and time for water absorption, resulting in a decrease in total mois- − 7.0 ± 0.9 days, p < 0.01, respectively. Another study by ture and volume of fecal waste products. Alosetron has been Camilleri et al. on 647 females with IBS-D or alternating associated with adverse events such as colon ischemia bowel patterns (IBS-A) yielded similar results. Patients were randomized into placebo vs 1 mg alosetron daily. It was found Table 1 Existing and emerging (*) IBS therapies that a greater proportion of participants in the alosetron group • IBS–Diarrhea reported adequate relief compared with the placebo (133 • Anti-diarrheals (41%) vs 94 (29%), respectively), for the 3 months of treat- – • Loperamide ment, with a statistically significant difference of 12% (4.7 • Diphenoxylate/atropine 19.2) between the groups. They also reported that patients in • Anti-spasmodics the treatment group had decreased urgency and stool frequen- • Dicyclomine cy and firmer stool texture [8]. • Hyoscyamine Currently, the use of alosetron is restricted to women with • Peppermint oil severe IBS-D without adequate response to conventional ther- • Antibiotics apy and with chronic IBS symptoms (greater than 6 months) • Rifaximin without any anatomical or biochemical abnormalities of the GI • 5-HT3 antagonists tract. Contraindications to the drug include history of chronic • Alosetron or severe constipation, strictures of the GI tract, history of • Ramosetron* perforation or adhesions, ischemic colitis, inflammatory bowel • Mixed opioid receptor agonist/antagonist disease, diverticulitis, and severe hepatic impairment. • Eluxadoline • IBS–Constipation Rifaximin • Laxatives • Osmotics Rifaximin is a gut-specific oral broad-spectrum antibiotic with • Stimulants very low systemic absorption and bioavailability. It primarily • Chloride channel activators acts by interfering with bacterial DNA transcription. Its exact • Lubiprostone effects on the generation and perception of IBS symptoms are • Guanylate cyclase receptor activators unknown, but leading theories suggest alterations in the gut • Linaclotide microbiome metabolism and/or host–microbiome interaction. • Plecanatide Two large randomized clinical trials (TARGET 1 and • Sodium/hydrogen exchanger 3 inhibitor TARGET 2) of 1260 IBS patients without constipation eval- • Tenapanor* uated the efficacy of rifaximin for improving IBS symptoms. Patients were randomized to receive 550 mg of rifaximin three Curr Gastroenterol Rep (2019) 21: 25 Page 3 of 7 25 times daily vs placebo for 2 weeks and then followed up for a improvement in groups randomized to 100 mg and 200 mg period of 10 more weeks. It was observed that a significantly BID dosing when compared with placebo. The 200 mg BID higher proportion of patients in the rifaximin group had ade- regimen was associated with more adverse effects, and there- quate relief of global IBS symptoms during the first 4 weeks fore, only 75 mg and 100 mg BID regimens were chosen for after treatment (41% vs 31% in TARGET 1 and 41% vs 32% phase 3 trials [14]. in TARGET 2) with a similar incidence of adverse effects [9]. The study population for the two phase 3 trials included Rifaximin has also been studied in a randomized trial in pa- patients who met Rome III criteria for IBS-D. Patients were tients with IBS-C (Rome II criteria), and this study found that randomized to receive either eluxadoline at a dose of 75 mg rifaximin
Load more

Recommended publications
  • Gastrointestinal (GI) Motility, Chronic Therapeutic Class Review
    Gastrointestinal (GI) Motility, Chronic Therapeutic Class Review (TCR) March 7, 2019 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. March 2019 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004–2019 Magellan Rx Management. All Rights Reserved. FDA-APPROVED INDICATIONS Drug Manufacturer Indication(s) alosetron (Lotronex®)1 generic, .
    [Show full text]
  • COMPARISON of the WHO ATC CLASSIFICATION & Ephmra/Intellus Worldwide ANATOMICAL CLASSIFICATION
    COMPARISON OF THE WHO ATC CLASSIFICATION & EphMRA/Intellus Worldwide ANATOMICAL CLASSIFICATION: VERSION June 2019 2 Comparison of the WHO ATC Classification and EphMRA / Intellus Worldwide Anatomical Classification The following booklet is designed to improve the understanding of the two classification systems. The development of the two systems had previously taken place separately. EphMRA and WHO are now working together to ensure that there is a convergence of the 2 systems rather than a divergence. In order to better understand the two classification systems, we should pay attention to the way in which substances/products are classified. WHO mainly classifies substances according to the therapeutic or pharmaceutical aspects and in one class only (particular formulations or strengths can be given separate codes, e.g. clonidine in C02A as antihypertensive agent, N02C as anti-migraine product and S01E as ophthalmic product). EphMRA classifies products, mainly according to their indications and use. Therefore, it is possible to find the same compound in several classes, depending on the product, e.g., NAPROXEN tablets can be classified in M1A (antirheumatic), N2B (analgesic) and G2C if indicated for gynaecological conditions only. The purposes of classification are also different: The main purpose of the WHO classification is for international drug utilisation research and for adverse drug reaction monitoring. This classification is recommended by the WHO for use in international drug utilisation research. The EphMRA/Intellus Worldwide classification has a primary objective to satisfy the marketing needs of the pharmaceutical companies. Therefore, a direct comparison is sometimes difficult due to the different nature and purpose of the two systems.
    [Show full text]
  • Guts and Butts: Treatment Options for IBS and Functional Dyspepsia
    7/2/2020 Guts and Butts: Treatment Options for IBS and Functional Dyspepsia Amy McCracken, DNP, APRN 1 Learning Objectives: ● Discuss the diagnosis and management of IBS and functional dyspepsia in order to optimize treatment strategies ● Describe pharmacological and alternative treatment approaches of IBS-C, IBS-D, IBS-M, and functional dyspepsia ● Articulate patient-specific treatment options for those with IBS and functional dyspepsia as derived from case studies 2 1 7/2/2020 Irritable Bowel Syndrome (IBS)-Definition and Epidemiology ● Comprises a group of functional bowel disorders in which abdominal discomfort or pain is associated with defecation or a change in bowel habits in the absence of an organic disease. ● The prevalence of IBS in North America is estimated at approximately 10-15%. ● More common in women compared to men. ● Second highest cause of work absenteeism ● IBS accounts for approximately 25 to 50% of all referrals to gastroenterologists. ● Important to remember: This is a diagnosis of exclusion! 3 IBS-Etiology ● Stress ● Visceral hypersensitivity ● Psychosocial factors ● Common-cannot be explained ● Chronic and benign ● High association with stress in the pathophysiology and clinical presentation of IBS 4 2 7/2/2020 IBS-Signs and Symptoms ● Chronic abdominal pain-usually a cramping sensation that varies in intensity with periodic exacerbations ● The character and location of pain can vary widely and often times related to defecation ● Abdominal fullness, bloating or swelling ● Diarrhea, constipation or alternating
    [Show full text]
  • New Treatment Options for Chronic Constipation: Mechanisms, Efficacy and Safety
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE CHRONIC CONSTIPATION – CHALLENGES AND REMEDIES provided by Crossref New treatment options for chronic constipation: Mechanisms, efficacy and safety Michael Camilleri MD M Camilleri. New treatment options for chronic constipation: De nouvelles options thérapeutiques contre la Mechanisms, efficacy and safety. Can J Gastroenterol constipation chronique : leurs mécanismes, leur 2011;(Suppl B):29B-35B. efficacité et leur innocuité The present review has several objectives, the first of which is to review the pharmacology and selectivity of serotonergic agents to La présente analyse comporte plusieurs objectifs, le premier étant de contrast the older serotonergic agents (which were withdrawn because réviser la pharmacologie et la sélectivité des sérotoninergiques pour of cardiac or vascular adverse effects) with the newer generation sero- comparer les anciens sérotoninergiques (retirés du marché en raison de tonin receptor subtype 4 agonists. Second, the chloride ion secret- leurs effets cardiaques ou vasculaires) avec les agonistes de récepteurs agogues that act through the guanylate cyclase C receptor are appraised de la sérotonine de sous-type 4 de nouvelle génération. En deuxième and their pharmacology is compared with the approved medication, lieu, les sécrétagogues des ions chlorures qui agissent par le récepteur lubiprostone. Third, the efficacy and safety of the application of bile du guanylatecyclase C sont évalués, et leur pharmacologie est com- acid modulation to treat constipation are addressed. The long-term parée avec celle du lubiprostone, un médicament approuvé. En studies of surgically induced excess bile acid delivery to the colon are troisième lieu, l’efficacité et l’innocuité de l’application de la modula- reviewed to ascertain the safety of this therapeutic approach.
    [Show full text]
  • Preferred Drug List 4-Tier
    Preferred Drug List 4-Tier 21NVHPN13628 Four-Tier Base Drug Benefit Guide Introduction As a member of a health plan that includes outpatient prescription drug coverage, you have access to a wide range of effective and affordable medications. The health plan utilizes a Preferred Drug List (PDL) (also known as a drug formulary) as a tool to guide providers to prescribe clinically sound yet cost-effective drugs. This list was established to give you access to the prescription drugs you need at a reasonable cost. Your out- of-pocket prescription cost is lower when you use preferred medications. Please refer to your Prescription Drug Benefit Rider or Evidence of Coverage for specific pharmacy benefit information. The PDL is a list of FDA-approved generic and brand name medications recommended for use by your health plan. The list is developed and maintained by a Pharmacy and Therapeutics (P&T) Committee comprised of actively practicing primary care and specialty physicians, pharmacists and other healthcare professionals. Patient needs, scientific data, drug effectiveness, availability of drug alternatives currently on the PDL and cost are all considerations in selecting "preferred" medications. Due to the number of drugs on the market and the continuous introduction of new drugs, the PDL is a dynamic and routinely updated document screened regularly to ensure that it remains a clinically sound tool for our providers. Reading the Drug Benefit Guide Benefits for Covered Drugs obtained at a Designated Plan Pharmacy are payable according to the applicable benefit tiers described below, subject to your obtaining any required Prior Authorization or meeting any applicable Step Therapy requirement.
    [Show full text]
  • Therapeutically Targeting Guanylate
    ORIGINAL ARTICLE Therapeutically targeting guanylate cyclase-C: computational modeling of plecanatide, a uroguanylin analog Andrea Brancale1 , Kunwar Shailubhai2, Salvatore Ferla1, Antonio Ricci1, Marcella Bassetto1 & Gary S Jacob2 1School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom 2Synergy Pharmaceuticals, New York, New York Keywords Abstract guanylate Cyclase-C, linaclotide, molecular dynamics, plecanatide, uroguanylin Plecanatide is a recently developed guanylate cyclase-C (GC-C) agonist and the first uroguanylin analog designed to treat chronic idiopathic constipation (CIC) Correspondence and irritable bowel syndrome with constipation (IBS-C). GC-C receptors are Andrea Brancale, Cardiff School of Pharmacy found across the length of the intestines and are thought to play a key role in and Pharmaceutical Sciences, Cardiff fluid regulation and electrolyte balance. Ligands of the GC-C receptor include University, Redwood Building, King Edward endogenous agonists, uroguanylin and guanylin, as well as diarrheagenic, VII Avenue, Cardiff, CF10 3NB. Escherichia coli heat-stable enterotoxins (ST). Plecanatide mimics uroguanylin Tel: +44 (0)29 2087 4485; Fax: +44(29) 2087 4149; in its 2 disulfide-bond structure and in its ability to activate GC-Cs in a pH- E-mail: [email protected] dependent manner, a feature associated with the presence of acid-sensing resi- dues (Asp2 and Glu3). Linaclotide, a synthetic analog of STh (a 19 amino acid Funding Information member of ST family), contains the enterotoxin’s key structural elements, Financial Support for this study provided by including the presence of three disulfide bonds. Linaclotide, like STh, activates Synergy Pharmaceuticals Inc. We also GC-Cs in a pH-independent manner due to the absence of pH-sensing residues.
    [Show full text]
  • ACG Clinical Guideline: Management of Irritable Bowel Syndrome
    CLINICAL GUIDELINES 17 ACG Clinical Guideline: Management of Irritable Bowel Syndrome Brian E. Lacy, PhD, MD, FACG1, Mark Pimentel, MD, FACG2, Darren M. Brenner, MD, FACG3, William D. Chey, MD, FACG4, 5 6 7 02/05/2021 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= by http://journals.lww.com/ajg from Downloaded Laurie A. Keefer, PhD , Millie D. Long, MDMPH, FACG (GRADE Methodologist) and Baha Moshiree, MD, MSc, FACG Downloaded Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients’ quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever from http://journals.lww.com/ajg American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the by following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms.
    [Show full text]
  • Update on the Management of Constipation
    Clinical Review & Education JAMA Insights | CLINICAL UPDATE Update on the Management of Constipation Arnold Wald, MD Chronic constipation is very common. The most recent estimate 2018. Prucalopride is a serotonin 4 receptor agonist that increases of clinician visits attributable to constipation were from 2001 to intracellular cyclic adenosine monophosphate to enhance release 2004 and reported more than 8 million clinician visits in the United of acetylcholine, a major excitatory neurotransmitter in the gastro- States, with most occurring in adult primary care settings (33%) fol- intestinal tract.6 Because of potential adverse events associated lowed by pediatric (21%) and gastroenterologist (14%) offices.1 with the low selectivity of previously released serotonin agonists These encounters result in large expenditures for nonprescription (cisapride, tegaserod), which led to their withdrawal from the US laxatives and other bowel movement aids, such as enemas market, there have been efforts to develop highly selective seroto- and suppositories. nin 4 agonists with low affinity for certain cardiac channels and Constipationmaybeassociatedwithaprimaryorsecondarymo- enhanced cardiovascular safety. Prucalopride was released in tor disorder of the colon, a defecation disorder, a large number of Europe in 2010 and Canada in 2011 for the management of CIC. diseases, or adverse events of drugs.2 A time-honored approach to However, it was not until 2018 that the FDA approved its use for managing constipation is to exclude an organic cause with appro- managing CIC based on 3 pivotal trials conducted in 2008 and priate testing and to consider 2009. This decision was largely due to the long postmarketing slow colon transit and defeca- experience in other countries to reassure those with lingering con- Related article tion disorders only when stan- cerns about cardiovascular safety.
    [Show full text]
  • Current and Emerging Concepts in Irritable Bowel Syndrome
    9/17/2020 Disclosures: Brooks D. Cash, MD, FACG Consultant/Speakers’ Bureau: Salix, Allergan, Takeda, Ironwood, Alfasigma, Arena DSMB: Vibrant Brian E. Lacy, MD, PhD, FACG No conflicts of interest. 1 Current and Emerging Concepts in Irritable Bowel Syndrome Brooks D. Cash, M.D., FACP, FACG, FASGE, AGAF Dan and Lillie Sterling Professor of Medicine McGovern Medical School Chief, Gastroenterology, Hepatology, and Nutrition University of Texas Health Science Center Houston, TX 2 American College of Gastroenterology 1 9/17/2020 Disclosures • Consultant/Speakers’ Bureau: Salix, Allergan, Takeda, Ironwood, Alfasigma, Arena • DSMB: Vibrant 3 Objectives 1.Discuss the pathophysiology and diagnostic criteria for IBS 2.Explore the data for lifestyle and over the counter therapies for IBS symptoms 3.Review the mechanisms of action, efficacy, and safety profiles of FDA approved IBS therapies 4.Examine emerging therapies for IBS 4 American College of Gastroenterology 2 9/17/2020 Rome IV Criteria for IBS Recurrent abdominal pain at least 1 day/week (on average) in the last 3 months associated with ≥ 2 of the following Related to defecation Associated with Associated with a change a change in stool form in stool frequency Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis Lacy BE, et al. Gastroenterology. 2016 McGovern Medical School 5 Multifactorial Pathophysiology of IBS Inflammation, Psychosocial Immune Factors Dysregulation Genetic Predisposition Microbiome Visceral Malabsorption Hypersensitivity Issues IBS Abnormal Symptom Diet Motility Complex Chey WD, et al. JAMA. 2015;313:949‐958. Drossman DA. Gastroenterology. 2016;150:1262‐1279. Holtmann G, et al. Dig Dis.
    [Show full text]
  • Functional Bowel Disease
    Functional Bowel Disease a b, Aiya Aboubakr, MD , Michelle S. Cohen, MD * KEYWORDS Functional gastrointestinal disorders Functional bowel disorders Irritable bowel syndrome KEY POINTS Irritable bowel syndrome (IBS) is a common functional bowel disorder that affects individ- uals regardless of age and gender and can result in impaired quality of life and significant health care resource utilization. The diagnosis of IBS is based on clinical symptoms using the Rome IV criteria; laboratory or radiographic abnormalities suggest an alternate diagnosis. IBS is categorized into 4 subtypes based on the predominant bowel habit: constipation, diarrhea, mixed, or unclassified. The treatment of IBS is individually tailored based on subtype, predominant symptoms, symptom severity, age, and comorbidities. Therapeutic options for IBS include dietary and lifestyle modifications, pharmacotherapy that alter gut function, neuromodulators, and psychotherapy. INTRODUCTION Functional gastrointestinal disorders (FGIDs), also referred to as disorders of gut-brain interaction, are among the most commonly encountered diagnoses in gastroenter- ology.1 Although these disorders can affect individuals regardless of age, gender, and race, they are more commonly diagnosed in women and at age 50 years or younger.1–3 The symptoms range in severity and can result in impaired quality of life, absenteeism, and significant health care resource utilization.4–6 FGIDs exist in a separate clinical domain from organic or motility disorders and relate to an “illness experience.”1
    [Show full text]
  • TRULANCE Safely and Effectively
    HIGHLIGHTS OF PRESCRIBING INFORMATION • Swallow tablets whole. These highlights do not include all the information needed to use • For patients who have difficulty swallowing tablets whole or TRULANCE safely and effectively. See full prescribing those with a nasogastric or gastric feeding tube, see full information for TRULANCE. prescribing information with instructions for crushing the tablet and administering with applesauce or water. TRULANCE (plecanatide) tablets, for oral use Initial U.S. Approval: 2017 DOSAGE FORMS AND STRENGTHS Tablets: 3 mg (3) WARNING: RISK OF SERIOUS DEHYDRATION IN PEDIATRIC PATIENTS CONTRAINDICATIONS See full prescribing information for complete boxed warning. • Patients less than 6 years of age due to the risk of serious dehydration. (4, 5.1, 8.4) • TRULANCE is contraindicated in patients less than 6 • Patients with known or suspected mechanical gastrointestinal years of age; in young juvenile mice, plecanatide caused obstruction. (4) death due to dehydration. (4, 8.4) • Avoid use of TRULANCE in patients 6 years to less than WARNINGS AND PRECAUTIONS 18 years of age. (5.1, 8.4) Diarrhea: Patients may experience severe diarrhea. If severe • The safety and effectiveness of TRULANCE have not diarrhea occurs, suspend dosing and rehydrate the patient. (5.2) been established in patients less than 18 years of age. (8.4) ADVERSE REACTIONS Most common adverse reaction (≥2%) is diarrhea. (6.1) INDICATIONS AND USAGE TRULANCE is a guanylate cyclase-C agonist indicated in adults for To report SUSPECTED ADVERSE REACTIONS, contact treatment of chronic idiopathic constipation (CIC). (1) Synergy Pharmaceuticals at 1-888-869-8869 or FDA at 1-800­ FDA-1088 or www.fda.gov/medwatch.
    [Show full text]
  • Therapeutic Class Overview Irritable Bowel Syndrome and Constipation Agents
    Therapeutic Class Overview Irritable Bowel Syndrome and Constipation Agents INTRODUCTION Irritable bowel syndrome (IBS) is a gastrointestinal disorder that most commonly manifests as chronic abdominal pain and altered bowel habits in the absence of any organic disorder (Wald 2017). IBS may consist of diarrhea-predominant (IBS-D), constipation-predominant (IBS-C), IBS with a mixed symptomatology (IBS-M), or unclassified IBS (IBS-U). Switching between the subtypes of IBS is also possible (Ford et al 2018). IBS is a functional disorder of the gastrointestinal tract characterized by symptoms of abdominal pain, discomfort and bloating, and abnormal bowel habits with bouts of diarrhea and/or constipation. The exact pathogenesis of the disorder is unknown; however, it is believed that altered gastrointestinal tract motility, visceral hypersensitivity, autonomic dysfunction, and psychological factors indicate disturbances within the enteric nervous system, which controls the gastrointestinal system (Andresen et al 2008, Ford et al 2009, Quigley et al 2012, World Gastroenterology Organization [WGO] 2015). Prevalence estimates of IBS range from 10 to 12%, and it typically occurs in young adulthood (Ford et al 2018). IBS-D is more common in men, and IBS-C is more common in women (WGO 2015). Symptoms of IBS often interfere with daily life and social functioning (WGO 2015). The general goals of therapy in IBS are to alleviate the patient’s symptoms and to target any specific exacerbating factors (eg, medications, dietary changes), concerns about serious illness, stressors, or potential psychiatric comorbidities that may exist (Wald 2017). Non-pharmacological interventions to combat IBS symptoms include dietary modifications such as exclusion of gas- producing foods (eg, beans, prunes, Brussel sprouts, bagels, etc.), and consumption of probiotics, as well as psychosocial therapies (eg, hypnosis, biofeedback, etc.) (Ford et al 2018).
    [Show full text]