Clinical care pathway

IBS is a highly prevalent, chronic gastrointestinal disorder that has a significant impact on patients' lives1

Successful management of IBS involves working closely with patients over time in order to provide education and find the most suitable treatment plan

IBS CounSEL clinical care pathway for IBS

Below are some key steps that may help guide effective long-term management of IBS

Patient education and reassurance

Encourage patients to lead discussions through patient-centered interviewing regarding their experiences, worries, preferences, and expectations; this can be reassuring to the patient and help improve outcomes2-6

Provide education regarding the causes and natural history of IBS7

Inform patients regarding common points of concern:

  • Symptoms are not life-threatening; focusing on creating a treatment plan to alleviate symptoms can provide optimism for patients that IBS can be successfully managed7,8
  • There is no increased risk of cancer in patients with IBS; careful explanations of the nature of the disease will help reduce fears7
  • There is no direct “cure” for IBS; reassurance and explanation of the disease course are vital7

The goal should be to develop a mutually agreeable management plan with realistic expectations7

Consider directing patients to patient websites for self-management tips and other resources

VISIT WWW.IFFGD.ORG

Lifestyle and diet

Encourage your patients to practice healthy habits, such as7:

  • Regular exercise, e.g. a 20-minute walk each day7
  • Good sleep hygiene, e.g. having a period of time for relaxation before going to bed, avoiding food or drinks with caffeine for at least 4 hours before bedtime, and refraining from viewing a TV screen before sleeping9
  • Healthy eating behavior, e.g. taking time over meals, sitting down to eat, and eating regularly10

Consider if symptoms appear linked to specific ‘triggers’, and if so consider if reducing/avoiding these is appropriate. Common triggers include11,12:

  • Caffeine
  • Artificial sweeteners (e.g. diet candies and chewing gum)
  • Spicy foods
  • Legumes (e.g. beans and lentils)
  • Dairy products
  • High-fiber foods

For more information on symptom triggers, please visit the symptom triggers page

Specialized diets, such as a low-FODMAP diet, may be appropriate recommendations based on the patient’s history and symptoms13-15

Consider providing patients with a symptom diary to help identify potential symptom triggers

DOWNLOAD THE PATIENT DIARY

Consider referral to a registered dietitian to discuss specialized diets

Psychosocial considerations

Anxiety, depression, and other psychological disorders may be present in some patients with IBS16; therefore, it is important to assess patient history and observe whether psychological issues are present17,18

Anxiety in patients with IBS may also be symptom-related and stress reduction may be beneficial19

The following relaxation techniques may be worth discussing with your patients based on their symptom history19:

  • Meditation
  • Deep breathing
  • Yoga

Consider referral to psychotherapist if psychiatric co-morbidity is present

Pharmacological management

Pharmacological interventions are often important and potentially necessary along with dietary and lifestyle changes7

Treatments should be tailored to the individual patient and take into account the severity of the disease (mild, moderate, or severe), which is typically assessed subjectively in practice based on frequency of symptoms and impact of symptoms on patients’ daily lives20

Over-the-counter medications that target specific symptoms, such as laxatives, antidiarrheals, or antispasmodics, may be appropriate for patients with mild IBS symptoms, and can often be used on an as-needed basis7

For patients with IBS-D, FDA-approved options, such as eluxadoline and rifaximin, should be considered, especially for patients with moderate-to-severe symptoms20

For patients with IBS-C, FDA-approved options, such as linaclotide and lubiprostone (for women with IBS-C), should be considered21

Other pharmacological options for treatment of IBS can be considered depending on the patient’s history and symptoms7

For more information on specific treatment options, please visit the management options page

Consider administering the IBS-QoL questionnaire

DOWNLOAD QUESTIONNAIRE

Reassessment

A regular follow-up every 1-6 months should be conducted to assess patient progress, depending on the patient’s personal and symptom history20

If patient symptoms are not improving, additional or alternative treatment options should be considered20

Consider referral to a gastroenterologist if symptoms persist

IBS management is an ongoing process. It is important to work with patients by providing information on lifestyle, diet, and pharmacological options to ultimately improve their quality of life20 This information is not a substitute for clinical judgment. Each healthcare provider is solely responsible for any decisions made or actions taken in reliance of this information. See full prescribing information for important risk information for any pharmacological treatment.
Learn more about IBS

References

  1. Longstreth GF et al. Gastroenterology 2006; 130: 1480-1491.
  2. Stewart MA. CMAJ 1995; 152: 1423-1433.
  3. Beck RS et al. J Am Board Fam Pract 2002; 15: 25-38.
  4. Platt FW et al. Ann Intern Med 2001; 134: 1079-1085.
  5. Lyles JS et al. J Clin Outcomes Manag 2001; 8: 28-34.
  6. Drossman DA. Am J Gastroenterol 2013; 108: 521-528.
  7. Chey WD et al. JAMA 2015; 313: 949-958.
  8. Hahn BA et al. Aliment Pharmacol Ther 1997; 11: 553-559.
  9. International Foundation for Functional Gastrointestinal Disorders. Sleep and Irritable Bowel Syndrome. Available at: http://www.aboutibs.org/signs-and-symptoms-main/sleep-and-irritable-bowel-syndrome-2.html . Accessed July 2016.
  10. McKenzie YA et al. J Hum Nutr Diet 2012; 25: 260-274.
  11. Böhn L et al. Am J Gastroenterol 2013; 108: 634-641.
  12. MacDermott RP. Inflamm Bowel Dis 2007; 13: 91-96.
  13. De Giorgio R et al. Gut 2016; 65: 169-178.
  14. DeWeerdt S. Nature 2016; 533: S108-S109.
  15. Pilcher H. Nature 2016; 533: S112-S113.
  16. American Gastroenterological Association. IBS in America Survey. 2015. Available at: http://ibsinamerica.gastro.org/ .
  17. Lembo TJ and Fink RN. J Clin Gastroenterol 2002; 35: S31-36.
  18. Mayer EA. N Engl J Med 2008; 358: doi:10.1056/NEJMcp0801447.
  19. Park SH et al. Asian Nurs Res 2014; 8: 182-192.
  20. Lucak S et al. Therap Adv Gastroenterol 2016; in press.
  21. Chang L et al. Gastroenterology 2014; 147: 1149-1172.