Management of Irritable Bowel Syndrome (IBS) via Virtual Care
As part of the benefits of joining the HealthTap Medical Group, doctors gain access to exclusive educational opportunities. On Sunday, March 21, 2021, at the monthly HealthTap Medical Group Webinar, Dr. Silviu Pasniciuc, a member of the Medical Advisory Board, presented the assessment, evaluation and management of Irritable Bowel Syndrome (IBS) via virtual consultation. HealthTap is delighted to share the learnings from his presentation below:
Good evening and thank you for having me. Well, first of all, thank you for giving me the chance to speak again. This is by no means a favorite... it's such a poorly understood complex of, I would say a spectrum of symptoms that, I think years ago, we decided to kind of put together under this generic name of irritable bowel syndrome. Again, I have a few slides. I'll try to stay in time here, but thank you, Geoff and Angela for putting this together, being patient with all the technical difficulties. And let's see if I can stay on time...
Again, out of the people affected with this disease and a couple of internal things, most of the slides, 90% of these slides are based on UpToDate. The brand says it is medical information basically updated the best we have it, there is an expert panel along with what the research, the recent research, brought up over the years. So it's a good combination. So I use it a lot in practice. That doesn't mean it's the best out there. It just summarizes the main changes that are in the field. So I trust it and, this is what I use here. So it's very little that I have from outside and, towards the end, we'll see a slide or two, based on my impression or based on how I would do it, you know. The second thing is, this is good company after listening to Dr. Saghafi and Dr. Machanic. And, this is not necessarily from my experience. So this is more of a review of the existing literature. That's a little different. That was fascinating, by the way. I feel I'm in good company there, you know, it's just for me, trying to kind of put together a few things that are good for review to refresh our memory, make sure we're up to speed. Out of these patients, only a small percentage actually seek medical attention. And this is because of the tolerance for the symptoms. As some people are extremely sensitive to GI symptoms, some other people are able to ignore it. The reality of it is we, all of us, we experience GI symptoms throughout our lives. It's just which ones-- is this a type of fibromyalgia of the GI system? If you want to look at it this way, um, meaning that poorly understood symptoms that affect an individual's life with really no objective findings at the end of the day, and then having to call them irritable bowel syndrome. So, that's where my understanding kind of has it right now. And then again, approximately 40% of these individuals, they actually never get a formal diagnosis, meaning that they have all these tests and they're, eventually told, okay, we don't know what's going on, keep going. Everything is okay. You know, things will get better. We have no reason to believe there is something wrong, but many times, about half of the patients, they never have it called as under irritable bowel syndrome. And we probably will see why, again, increased costs with it. And then, the majority are from, once the primary care, usually they feel that there is something there, they get referred to a gastroenterologist, to specialists eventually. But again, we're not aware of a cure for this disease. So once diagnosed, this is something, this is a chronic disease by definition. This is not something that will last for a couple of months, or we have a treatment that will cure it right there for two weeks of a treatment, and then the irritable bowel syndrome goes away. So we don't have the cure, it's like a diabetes or hypertension that needs to be addressed each and every time. And that takes time and becomes definitely a burden on the medical system.¶
Let's move to the next slide if we could. And then what's the ideology? Well, we don't know. I mean, it's definitely somewhere in the gut brain axis, it has to do with motility, has to do with pain, sensitivity, possibly infections contributing, either it is a trigger for the irritable bowel, or along the way, we have this bacterial overgrowth. At times, I feel there is an overlap, many times, and when we revisit one of the treatments we'll see that. Probably, this is the way it makes sense that some of the drugs work a little better than others. Again, genetic factors, some sensitivity to specific food. A typical history usually includes an infectious event or a stressful life event. And usually this is how the disease gets discovered and then treated.
The prevalence, I found was different in these citations, which are still from UpToDate. So in case anybody needs to, if you open UpToDate, you'll find the actual articles in there where, this is about 10 to 15% in North America, estimated, with a prevalence lower in the elderly, as we age, and then slightly higher in women. IBS, and this is critical, is associated again with fibromyalgia. I already called it a fibromyalgia for the GI system and then chronic fatigue, which has changed its name a little bit lately-- Here it is systemic exertion intolerance disease, but the most important is psychiatric disorder. Up to 80 to 90% of these patients-- they are either diagnosed or undiagnosed, but they do suffer from either anxiety disorder, depression, or somatization disorder. This is a critical, I think, overlap because trying to address one without the other might not be fruitful in the long range, in the medium to long range.
Irritable bowel is to be suspected in patients with chronic pain and altered bowel habits. In the differential at a minimum: celiac disease, microscopic colitis, inflammatory bowel disease, colon cancer, as well.
Now, one problem for us, you know, in medicine, there is always subjective and objective. There'll be no test that will be diagnostic for IBS. IBS is more of an exclusion diagnosis where specific conditions will have to be ruled out and then eventually the diagnosis formulated. So, there are no specific antibody tests like we have in celiac disease. There is no specific stool study that will make us think that this is an irritable bowel syndrome. So we have to rule out the others to leave the possibility of irritable bowel as a diagnosis. So in here, the authors are in this article in UpToDate regarding irritable bowel, they recommend, at least a CBC in all patients. In patients with diarrhea specific, the fecal calprotectin and fecal lactoferrin, they, specifically are markers of inflammation. So that will send the diagnosis more towards the inflammatory bowel disease spectrum. And then they recommend also stool testing for Giardia. Again, this is IBS D, and also serologic testing for celiac disease, C-reactive protein only if there is some sign of inflammation.
And then, never forget about the colonoscopy, specifically if age appropriate with a family history and specifically in an urgent care setting where I think our attention is mostly in trying, once we accept that we can influence only partially the course of the disease, we need to rule out acute things that might mimic just the progression of the disease. So, a colonoscopy will always be there in case the patient's never had one, specifically, they have colonoscopy age or significant family history. So, next they also recommended some tests specifically for, these are very, kind of involved tests that are not done, usually not in clinic, but for IBS-C constipation.
Now, among the features that should prompt further tests, there is the age. If it's late in life, that's not typical for IBS. It doesn't mean it doesn't exist. It's just something that, we might need to think about some other reasons for the symptoms at the time. And then there's rectal bleeding, of course, the diarrhea at night, and then, the abdominal pain trending towards worse, weight loss, of course, and then any lab abnormalities, they'll entertain more of a somatic diagnosis, some something else going on. And then of course, a family history.
[Dr. Geoff Rutledge]: I was going to say if I may comment, Silviu, this is a great list of things to think about. If someone presents in a virtual consultation saying, I have IBS, I want this treatment. One of the, this is a great list of things to consider saying, well, let's run through a mental checklist, make sure they don't have any of these things that would make me question whether I should just treat as IBS and move on versus underscore the importance of seeing the gastroenterologist as a next step and prior to even considering additional IBS treatments.
[Dr. Silviu Pasniciuc]: Absolutely. Thank you. Yes, that's a good point. Now, busy slide, but we always forget about meds. I don't know, almost any patient that’s not on a statin, on a blood pressure medicine, that they have taken an antibiotic somewhere along the last couple of months. And you'll have all, or somebody, that's not using alcohol at all, sorbitol. So, if you only look at this list, you'll find almost the most common drugs that most of the patients specifically after 30 or 40, they will be on. So that's where the hard work starts in making sure there is nothing-- you have the statins, you have diuretics, you have the majority of the blood pressure, including the most common one, the ACE inhibitors, and there is everything you want on this list that definitely will have to be questioned at the time. You know, you see this patient, you have supplements, you have, again, the sugar substitutes, you have all the NSAIDs, very common. I mean, who's not taking here and there an Advil or something for an ache or something? And then, you don't even realize that you end up taking a couple of them a day and this has been going on for a couple of months. And then all of a sudden, you get the diagnosis of irritable bowel syndrome. All you have to do is just stop, slow down the NSAIDs, and then all of a sudden things will get better. So this is probably a critical slide, again, and that takes some detective work making sure, and that's where knowing, getting to know the patient and making sure you review their medications becomes critical.
And this is a shorter list, probably. Again, this will be the constipation type, shorter, but again, you've got the antihypertensives, you've got the calcium channel blockers. You've got the anti-histamines, you've got typically used drugs by almost everybody, at least, for short periods of time. So, that's the first step in trying to kind of eliminate possible triggers for symptoms that might otherwise be classified under the big IBS syndrome.
Moving on, again, this is repeating some information, but, these are the conditions: celiac disease, colitis, bacterial overgrowth, inflammatory bowel disease, big mimickers and conditions that at any given time they, the patients, can still develop on an irritable bowel or and they'll have to be, whenever there is a change in pattern, they'll have to be considered.
And then, what's very important for proper care for these type of patients is establishing a relation with a specific doctor or group of doctors, because this is how trust and access to reliable information is built. When somebody is working on something, trying to rule out, rule in things, you need a little time, it's just the thing that patients lose their patience in that process. And then when it becomes difficult to get access to the information, make sure things are not ruled out before they are actually ruled out in, and moving on and progressing to treatment. So the patient clinician relationship is really critical in influencing the pattern of this disease. For mild to moderate symptoms, it's not even recommended to move to pharmacotherapy at that time.
Lifestyle changes are first, and then diet changes. What we see right now is FODMAP. It's basically fermentable saccharides. And that's where I think, again, another process, a very kind of tedious process of sorting out their food, plus lactose and gluten, so important things to either rule out or rule in, and I'm trying to adjust in order to figure out if there are specific types of food causing these symptoms.
The next slide will go even in detail. So these are some, and if you look, it's almost all vegetables, it's all a bunch of fruit and there is also milk and dairy. I mean, it will be really hard to remove all, but again, partially reducing some of them, trying to look and then keeping a log. I think here, which in my experience, I didn't read too many cases, but I think a food and symptom log may help in sorting it out. So these patients will take some time for them to build this kind of log: this is what I had to eat that day, this was what the symptoms were, or I didn't have any symptoms and this is what I had to eat. And then looking at the pattern and being able to kind of sort them out a little bit. So this is very important before therapy for irritable bowel.
[Dr. Geoff Rutledge]: This list actually brings up a question. I don't know if you know the answer to this, but in highlighting the foods that lead to flatulence, that are stimulants to IBS, do treatments for flatulence work for IBS? I'm thinking in particular, you know, Beano, the galactosidase pills that you can take, tablets that you can chew, that avoid or stop flatulence.
[Dr. Silviu Pasniciuc]: At least partially, I still believe knowing what's causing the problem and adjusting the volume of the food. If you say, if I really enjoy a specific food that I know is going to cause that type of problem, trying to get to the right volume, that's not going to cause significant trouble. Once you go to the pills, then you, in my experience, there might be some partial help, but the distress, the tension is already built as the symptoms are already there.
[Dr. Geoff Rutledge]: Just avoid the stimulus rather than treat it.
[Dr. Silviu Pasniciuc]: That's the idea to try to avoid getting in the symptom range, I think.
[Dr. Geoff Rutledge]: Yes, I would comment that Dr. Rhoads also weighs in saying that she wanted to emphasize that sucralose or Splenda and, to some extent, Stevia can cause significant GI distress also, whereas Equal and saccharin do not. So that’s interesting to point out.
[Dr. Silviu Pasniciuc]: Thank you. So what is helping? Physical exercise, gluten, and again, I was not aware, but it's not just celiac disease. There is also gluten sensitivity, not to the extent of the actual disease. So, there is a degree of gluten sensitivity that once gluten is avoided, then the symptoms will fade away and then fiber, specifically for the constipation type. And then, in cases that are really testing for food allergy, that otherwise is not recommended.
And then, this is what they recommend--I'm not sure if we're doing okay with time here. We're going over time a bit. So it's always, you start low, with typical symptom based treatment, with fiber, if this is, IBS, constipation type, and then the treatment is advanced to the newer drugs, including the lubiprostone, the plecanatide. And then, tegaserod, some of them I've never used myself, maybe linaclotide. So I really don't have experience and I can't comment on how well they work. The statistics and everything that's behind them, does show benefit, but the benefit is moderate. We'll get to see with one of them, the antibiotic, we'll get some numbers there, hopefully we'll be able to see on the next slide.
Again, this is IBS diarrhea type and starting with a mild anti-diarrheal, Loperimide, moving through bile acid sequestrants and then, Eluxadoline. I'm not sure if I'm pronouncing it right, never used it, newer drug. Again, I'm more experienced with dicyclomine, which is Bentyl, and then hyoscyamine, usually used for the old spastic bowel, as we used to call it. They work generally well, to be used as needed, and then antidepressants and then antibiotics. Among them, that is the Rifaximin, for a two week trial. And it will only make sense in IBS related to either bacterial overgrowth or some type of a microbiome alteration that somehow that antibiotic will re-establish the flora in the gut that won't cause the symptoms. The main problem with, if we can go to the next slide, with the Rifaximin, is that that's not the cure.
That's only to be used for a very limited amount of time in the studies. I'm going to simplify this because there is lots of information, but if you look at 41 versus 32% of the global IBS symptoms, there were 9% that benefited from the use of Rifaximin. And then that makes it a number needed to treat about 1 out of 11, which is good. But again, it's not changing massively the whole picture; it's probably okay to give it a try in the right context. If, and this is in my experience, if I work this patient up and I know exactly that we're getting there and if I'm questioning bacterial overgrowth, then giving it a trial, that will indirectly give me a sense of what's going on, like through the trial or the response. But, then never recommend more than a couple of courses of Rifaximin. And then, what if this is indeed IBS, then in about a year, what's next?
[Dr. Geoffrey Rutledge]: It's probably worth underscoring here because we may see, we have seen patients who come actually requesting Rifaximin as a trial. The many such patients as you've described have a chronic waxing and waning of symptoms, many patients have previously seen gastroenterologists, had the colonoscopy, have tried different treatments. Some of the other treatments have significant side effects, also, as you understand, the anti-cholinergics, and so on. My take is that Rifaximin is relatively benign in terms of the side effect profile, as a non-absorbable antibiotic. Did you have opinions about, if someone met all those criteria and said confidently it's IBS, with a previous evaluation and requesting a trial to see if it helps them with IBS-D, would you personally be inclined to grant that request for a two week trial with followup and a gastroenterologist? Do you think that's a reasonable thing or not? Because, as I say, we are seeing patients with just that scenario on HealthTap.
[Dr. Silviu Pasniciuc]: I think that's reasonable. It's just the fact that it's hard, you know, in an urgent care, regardless if it's remotely or not, if you don't have access to medical information, it’s hard and we see now more and more patients that are, many of them are self-diagnosed, self-treated in trying to kind of shortcut the, the little delays in the medical system, to say the least, a little crisis in the medical system, meaning that they become frustrated with the symptoms. They sometimes don't get to see their doctor at the right time. They struggle. And then, they start reading and many times they, you know, they might be right. They might have it, and the diagnosis is there and everything is there. I would not mind again, if I had some access to some information, if I have a good way of communicating with their gastroenterologist, the main problem is if they were diagnosed, they should be seeing their gastroenterologist or their primary care. It's not like they don't know they have a specific-- I'm just worried that they start abusing this because it's working and they, at some point, they say, well, I need to stay on it. And they keep requesting it, and at some point, either the primary care or the gastroenterologist, they tell them they can't stay on this medicine and then maybe they go online and then they can find it. But I think for a one-time, it should be okay. But if that patient starts coming a couple of times, three times…
[Dr. Geoffrey Rutledge]: That's a really important point, Silviu, you make, you know, we've said that it's acceptable for doctors in urgent care to give it once and to encourage or to require follow-up--to tell people, Hey, this is a one-time only thing. One of the things that occurred to me that you could recommend is if someone sees a patient like this in urgent care, and doesn't think it's appropriate or thinks the medical history needs more time to get to know them, and it's just not enough time in an urgent care visit, such a person could also be referred to the Virtual Primary Care clinic, where a doctor could spend longer. And the same doctor could see the patient over time. So that doctor could coordinate with the gastroenterologist or with an in-person doctor and still accomplish what the patient's asking for, which is a virtual visit for evaluation of whether or not this is the right thing. But I didn't want to interrupt you, we're just a couple minutes past the hour. I wanted to comment to the other doctors on the call, that we're going to continue and let Dr. Pasniciuc finish this presentation, but we have reached the end of the hour. So no one will be offended if you need to move on after the hour. But, Silviu, I'm going to suggest you continue and finish up your talk here.
[Dr. Silviu Pasniciuc]: Sure, thank you. Absolutely. Let's see if we can get through a couple of slides. Because I think in one of them, that's my personal take, so what is missing in urgent care? And that's exactly-- the time limitations for such a complex, sophisticated spectrum of symptoms and- it’s really, we have 15 minutes to half an hour, it's almost impossible to sort through, even if you had access to information. So, time limitations, that's big, and then access to medical documents, what was done, what's missing? It's really a very kind of delicate and time consuming process. And, what's missing on the patient's side? Many times, they don't understand the different settings. If you go with a chronic disease to an acute setting, there is a higher risk for them to get some treatment for something that nobody really could figure it out. With limited time, because again, the attention for the provider will be to the acute situation, rather than chronic and little exacerbations, because then they'll refer to the physicians that know their condition. And then there is, I see more and more, and this is again, some of my contribution, internet use, either beliefs or urgency. This is also from my other side, giving consults, many times, I see patients that are convinced that they need a specific treatment and then you take some time to sort through-- okay, these are the guidelines, these are your symptoms, this is what we know, and it doesn't really sound... It's really hard to make their point, meaning that they feel an urgency, and many times I've seen, not many times, but a few times, simply angry patients. Like they feel that something is being taken away, but I'm trying to use my best judgment in trying to help them, but it doesn't seem like this is what they're looking for. And that's where they're all…
[Dr. Geoffrey Rutledge]
We've all encountered difficult patients in that setting, Silviu, I completely resonate with what you're saying. Again, I will repeat that if you encounter a patient meeting those criteria, one avenue that's now available to the doctors is to refer such patients to virtual primary care, which they can do on the same day, they can schedule it within two hours, a visit to have a doctor who can then see the same person repeatedly. And so getting to know someone and all the things you've talked about are really quite...bring home to me, the notion that you really need to understand the history and really-- are they on any of the medications? What evaluation's been done? Have they really seen a gastroenterologist what's worked and what hasn't? Those are all valuable, important items to truly understand our patients before deciding the right course of treatment.
[Dr. Silviu Pasniciuc]: And of course, thank you. And the last is the medical system. You know, the things that are unclear, the waiting time, and that's building massive frustration, the communication-- is the patient aware that irritable bowel syndrome is incurable? After seeing for years, you might hear that now, that there should be something, we didn't find it yet, but unfortunately that's not supported by our medical knowledge. So, many times these patients are looking for a solution and an ultimate solution to their problem, which there is no such solution.
[Dr. Geoffrey Rutledge]: So how about having a doctor that knows you, that holds your hand and guides you through the ups and downs as they happen?
[Dr. Silviu Pasniciuc]: Absolutely, absolutely. Down to the last slide here, this is a difficult to treat condition, it's poorly understood at our end, frustration accumulating for patients and their caregivers, there are more and more drugs available, and this is good. This is good because that gives us enough to work with. It's just being in the right setting and having the knowledge, understanding the patient, establishing that communication, reliable ways of communicating, and trust. Trust is critical to treat this disease. And then don't forget about multi-modal treatment, make sure the anxiety, whatever is already overlapped in that disease needs to be addressed because otherwise we're going to end up overusing drugs for these patients, and then, setting remains critical. And then there's a growing number of patients self-diagnosing and self-treating, and that's where communication and making sure we set clear expectations. We have a clear discussion and with whatever is known and what's unknown or poorly known, I think that is probably, at this point, best practice.
[Dr. Geoffrey Rutledge]: So that was a wonderful presentation. Thank you so much for taking the time to review. I appreciate we're also beyond the planned time. So if people need to jump off, that's fine. But if you wouldn't mind holding on, if there are additional questions that people have, would you be willing to take questions that people might have?
[Dr. Silviu Pasniciuc]: Absolutely. Again, it's mostly my knowledge. I did treat two patients, but I'm by no means a specialist in this.
[Dr. Geoffrey Rutledge]: Well, but you're the one that did the review and has the recent information at hand…People have questions. We didn't talk about the other one, the Trulance, plecanatide. I think your slide put it into the context of one of the available ancillary treatments, which can be tried in people who have tried the other methods. It's not a first-line drug by any means. Some people will come also to HealthTap requesting Trulance. And I think all the same caveats apply, have you really tried- do we know that it's IBS? Is there no alert or alarm that it might be something else, but if they've been fully evaluated, clearly have IBS, have tried prior treatments, have learned about this new one and are asking, can they give it a try? I have no problem with doctors giving it a try, as long as they can enforce and reinforce the need for follow-up with a doctor who knows them, either an in-person doctor, that they know, a family doctor. If they haven't seen a gastroenterologist, they need to do a gastroenterology follow-up. If they want to be followed virtually, and they're going to come back to urgent care regardless, I would much rather they come back to Virtual Primary Care where they can see the same doctor each time. And we should encourage people to recognize that you can't get the same treatment repeated by a different doctor each time. You need to have a doctor who knows you for this, like so many ongoing chronic conditions. You need a doctor that knows you, who would have any clue about what the right thing to do is on an ongoing basis. On that happy note, I think we should- go ahead, Silviu.
[Dr. Silviu Pasniciuc]: Again. I have no experience myself using plecanatide. Again, I don't see a problem if the other... and again, each and every physician, I think that the best we can do is, they should make their own decision, based on their judgment at the time. Do you have enough information? Is it reliable information that you can move on? Do you feel comfortable? So, each and every one of us should use their best judgment at the time. Meaning that, I can’t say, you should never use it, or you should always use it. It's just based on the impression with the information you're given at the time. Of course, you know, using such a drug, which is advanced, always, I would like to ask, when is the last time when you saw your doctor, either the primary care who's been treating your condition and where did you leave it at? Was, did you request, was it a decision maybe to escalate your therapy at that time? And if that was the case, why didn't this happen already? And then they might say, okay, I had to leave and there was something else, or they left their practice and I'm in process of it. And that's a good excuse for that reason, meaning that, sure I can work with it. That's understandable. But if, no, because they didn't know what they were doing and I didn't...Then for me that's usually a red flag. That means they lost trust in a physician that they worked with. And even though you still might consider in this specific setting offering them a trial, they definitely need to reestablish at that point. So, trying to kind of convince them to get established at the ground level with the gastroenterologist, because again, this is a lifelong disease, so whatever we'll be trying here for a month or a couple of weeks, that's not going to cure the disease. So that's a good point to make.
[Dr. Geoffrey Rutledge]: One of the things that your conversation, your description today has triggered to me is- Gee, maybe we need to do more to divert patients interested in this treatment to get a virtual primary care doctor as a point of first contact to avoid this issue of an urgent care physician encounter, trying to untangle this very, what can be complex, set of issues. There may be more we can do upfront to prevent the person ever trying to do an urgent care visit for this problem, as opposed to encouraging them to pick a doctor. And you have a first visit to discuss these issues. Is this really the right way to handle it? Silviu, again, we're now 15 minutes past the planned hour. I wanted to thank all the doctors who had stayed with us through the encounter today and, appreciate the sound effects.
[Dr. Silviu Pasniciuc]: Thank you.
[Dr. Geoffrey Rutledge]: One of the questions was: can we get a copy of the slide deck? Would you mind if we circulated, just make a Google doc and just the slides in it and share a link to that?
[Dr. Silviu Pasniciuc]: Absolutely.