Name:

DOB:

PHN/ULI:

RHRN:

RefMD: Dr.

RefMDFax:

RefDate:

DateToday: CONFIRMATION: ReferralReceived

IBSTRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearDr.,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithirritable bowel syndrome (IBS). Based on full review of your referral, it has been determined thatmanagementof thispatientwithin theEnhancedPrimaryCarePathway isappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. FocusedsummaryofIBSrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail

ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.If your patient completes the Enhanced Primary Care Pathway and remains symptomatic or ifyourpatient’sstatusorsymptomschange,anewreferralindicating‘completedcarepathway’or‘newinformation’shouldbefaxedtoGICentralAccessandTriageat403-944-6540.Thankyou.

KevinRioux,MDPhDFRCPCMedicalLead,GICentralAccessandTriageSectionofGastroenterology

Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME March 2016 - Page 2/6

EnhancedPrimaryCarePathway:IBS

1.FocusedsummaryofIBSrelevanttoprimarycare

Irritablebowelsyndromeisacommonsymptomcomplexcharacterizedbychronicabdominalpainandabnormalbowelfunctioninabsenceoforganiccause.ThesekeyfeaturesofIBScanbewidelyvariableinseverityandmayremitandrecur,oftenbeingaffectedbydietaryfactorsandvariousstressors.Reliefof abdominal discomfort after bowel movement is a defining feature. Bowel dysfunction includesfrequent bowel movements, fecal urgency and even incontinence, altered stool form (hard/lumpy orloose/watery),incompleteevacuation,strainingatstool,andpassageofcopiousmucus.IBSisfrequentlyassociatedwithothergastrointestinalsymptomsincludingbloating,flatulence,nausea,burping,earlysatiety,gastroesophagealreflux,anddyspepsia.Extra-intestinalsymptomsalsofrequentlyoccurinIBSpatientsincludingdysuriaandfrequent,urgenturination,widespreadmusculoskeletalpain,dysmenorrhea,dyspareunia,fatigue,anxiety,anddepression.DiagnosticcriteriaforIBS(e.g.RomeIV)weredevelopedforuniformityofpatientrecruitmentinclinicaltrials. Inclinicalpractice,suchcriteriaonlyprovidea framework forassessingpatientswithsuspectedIBS;indeedthesecriteriaalonearefarbetterforrulingoutIBSthanrulingitin.TheconfidentdiagnosisofIBSreliesonpresenceoffoundationalsymptoms,recognitionofintestinalandextra-intestinal symptomsandpsychological stressors that support the IBSdiagnosis,detailedmedicalhistoryandphysicalexaminationaswellas judicioususeof investigations to identify red flag featuresandexcludeorganicconditionsthatmimicIBS.Treatment of IBS involves initial reassurance, dietary, psychological, behavioral interventions,pharmacotherapy based on dominant symptoms, and scheduled patient clinical review, reappraisal,support,andguidance.2.Checklisttoguideyourin-clinicreviewofthispatientwithIBSsymptoms

o RomeIVcriteriaforIBS:Recurrentabdominalpain≥1dayperweekinthelastthreemonthsrelatedtodefecationorassociatedwithchangeoffrequencyand/orform(appearance)ofstool.

o Absenceofredflagfeatures(bleeding,anemia,weightloss,nocturnalorprogressivesymptoms,onsetafterage50)

o Nofamilyhistoryofinflammatoryboweldisease,colorectalcancer,orceliacdisease

Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME July 2016 - Page 3/6

EnhancedPrimaryCarePathway:IBS3.Linkstoadditionalresourcesforpatients

CanadianDigestiveHealthFoundationUnderstandingIrritableBowelSyndromehttp://www.cdhf.ca/en/disorders/details/id/12

UpToDate®–BeyondtheBasicsPatientInformationaboutIBS(freelyaccessible)http://www.uptodate.com/contents/irritable-bowel-syndrome-beyond-the-basics?source=search_result&search=ibs&selectedTitle=2%7E1504.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofIBS,frombothGastroenterologyandPrimaryCareliterature:

DrossmanDAandHaslerWL.RomeIV—FunctionalGIdisorders:Disordersofgut-braininteractionGastroenterology2016;150:1257-61http://www.gastrojournal.org/issue/S0016-5085(15)X0019-9Weinbergetal.AGAInstituteGuidelineonthepharmacologicalmanagementofirritablebowelsyndrome.Gastroenterology2015;147:1146-8http://www.gastrojournal.org/article/S0016-5085(14)01089-0/abstract

KuritzkyL.IndividualizingPharmacologicManagementofIrritableBowelSyndrome.JFamPract.2015;64:S16-21.http://admin.imng.com/fileadmin/qhi/jfp/pdfs/CME_-_Hot_Topics_IBS_article_2.19.16.pdf

Wilkinsetal.DiagnosisandmanagementofIBSinadults.AmericanFamilyPhysician2012;86:419-426http://www.aafp.org/afp/2012/0901/p419.html

The following is a best-practice clinical care pathway for management of irritable bowelsyndrome in the primary care medical home, which includes a flow diagram and expandedexplanationoftreatmentoptions:

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Enhanced Primary Care Pathway: IRRITABLE BOWEL SYNDROME July 2016 - Page 5/6

FlowDiagram:IBSDiagnosisandManagement-ExpandedDetail1. Diagnosis of IBS isbasedonRome IV criteria (2016)of abdominalpain related todefecationand

associated with change in stool frequency or form. IBS requires very little initial laboratoryinvestigation – CBC, ferritin, and celiac disease screen according to most guidelines. The fecalimmunochemical test (FIT)hasnotbeenvalidated for investigationof IBS-likesymptoms;orderingFITinthiscircumstanceisinappropriate.Anemiaorotherredflagfeaturesincreasethelikelihoodoforganic disease and mandate referral to GI. Absence of red flags, however, does not completelyexcludethepossibilityoforganicdisease.Variousother intestinalandextraintestinal featuresoftenco-exist with IBS and provide support to the diagnosis. It is estimated that unrecognized organicdisorderswillbepresentinabout15%ofpatientswhomeetRomeIVcriteriaanddonothavealarmfeatures.Themost commondiseases that aremislabeledas IBSare celiacdisease,Crohn’sdisease,andmicroscopiccolitis. If C-reactive protein is ≤ 0.5mg/dL, the probability of IBD is ≤1%.GIcancersareveryunlikelyinpatientsthatmeetusualcriteriaforIBS.Adetailedmedicalhistoryandphysicalexaminationshouldbeperformedatpresentationtoassessfor a multitude of other conditions that mimic IBS. A careful review of medications should beperformed to identify ones that may be causing GI side effects (e.g. PPI, ASA/NSAIDs,laxatives/antacids, iron/calcium/magnesium supplements, calcium channel blockers,antidepressants,opioids,diuretics,herbalproducts).

2. General principles of IBS treatment. All patientswith IBSwill benefit from lifestyle and dietarymodifications,andthismaybeallthatisrequiredinthosewithmildorintermittentsymptomsthatdo not affect quality of life. Key to long-term effective management of IBS is to provide patientreassuranceoftheinitialdiagnosisIBSandofferpointsofreassessmentandreappraisaltoestablishatherapeuticrelationship.Connectingpatientswithresourcesfordiet,exercise,stressreduction,andpsychologicalcounselingisimportant.Screenforandtreatanyunderlyingsleepormooddisorder.

3. Specific approaches based on IBS subtype.Thereare threeclinicalphenotypesof IBS:diarrhea-

predominant(IBS-D),constipation-predominant(IBS-C),andmixedpatternalternatingdiarrheaandconstipation (IBS-M). Categorizing IBS by dominant GI symptom guides focused use of a fewadditionalinvestigations(particularlyinIBS-D),butalsoguidesspecifictreatmentapproaches.UseofpharmaceuticalsinIBSisgenerallyreservedforthosewhohavenotadequatelyrespondedtodietaryandlifestyleinterventions,orinthosewithmoderateorseveresymptomsthatimpairqualityoflife.Pain and bloating is a defining feature of IBS and, in some patients, these features are severe orfrequentenough toaffectqualityof life.Antispasmodicsmaybebeneficial inmanagingorabortingacute episodes of pain, andpatients often take reassurance in having these on-demand treatmentsavailable. For chronic IBS pain, tricyclic antidepressants have shown benefit, andmay have addedbenefitsinthosepatientswithmoodorsleepissues.In absence of alarm features, what would prompt referral for GI consultation and possiblecolonoscopy? Colonoscopy may be helpful in patients with diarrhea predominance who havepersistent symptomsor limitedbenefit fromusual treatments.This ismainly to assess forCrohn’sdiseaseandmicroscopiccolitis. Inpatientswithconstipationpredominanceoralternatingdiarrheaandconstipation,colonoscopyisveryunlikelytoyieldrelevantfindings.

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PrinciplesandSpecificsofIBSManagementbySubtype

AllsubtypesofIBS

Exercise Moderatetovigorousexercisefor20-60minutes3-5xperweek

SolubleFibreUseinIBSremainscontroversial,asmaybebeneficialinsomebutdetrimentalinothers.Reasonabletotrypsylliumhuskone-halftoonetablespoondaily.Insolublefibrelikebranisnotbeneficial.

Probiotics Bifidobacteriuminfantis(Align®)1capsule/d($40/mo.)Lactobacillusplantarum229v(TuZen®)1-2capsules/d($40-80/mo.)

Antispasmodics

Peppermintoil(0.2to0.275mLcaps,entericcoated)2capsulesBID($20-25/mo.)HyoscineButylbromide(Buscopan®)10mgTID-QID($25-40/mo.)Dicyclominehydrochloride(Bentylol®)20mgTID-QID($25-40/mo.)PinaveriumBromide(Dicetel®)50-100mgTID($50-75/mo.)Trimebutine(Modulon®)100-200mgTID($40-80/mo.)Allprescribedantispasmodicmedicationsshouldbefullydiscussedwiththepatientintermsofspecificrisksandsideeffectsandappropriatenessofuseincontextoftheirfullmedicalhistory

Antidepressants

Nortriptylineoramitriptyline10-25mgqhs,doseescalateby10-25mg/wkMayrequire25-150mg/d($20-60/mo.);usuallytakes2-3mos.forpeakeffectParticularlyusefulinpatientswithdiarrheaandpainpredominanceorsleepissues/anxiety/depressionUsewithcautioninpatientsatriskofprolongedQT;notesomnolenceandanticholinergicsideeffectsLatestIBStechnicalreviewdoesnotendorseuseofSSRIs

ComplementaryTherapies

PsychologicaltreatmentsMindfulness-basedstressreduction(www.thebreathproject.org)HypnotherapyAccupunctureYoga(www.yogacalgary.ca)

Diarrhea-PredominantIBS

Antidiarrheals

Loperamide(Imodium®)2-4mgBID($25-50/mo.OTC)Cholestyraminepowder(Olestyr®$0.40/g),colestipol(Colestid®$0.25/g)tabletsorpowderorcolesevelam(Lodalis®$1.80/g)tabletsorpowder,1-4gpoOD-TIDEspeciallyusefulpost-cholecystectomy.Adviseregardingtimingwithothermedicationstoavoidinteraction;iflongtermuse,riskoffatsolublevitamindeficiencies

FODMAPs CanadianDigestiveHealthFoundationcdhf.ca/bank/document_en/32-fodmaps.pdf

GlutenAvoidance Nonceliacglutensensitivity

Antibiotics Rifaximin(Zaxine®)550mg3x/dailyfor2weekswhichcosts~$325!

Constipation-PredominantIBS

PEG-basedLaxatives Mira-Lax®orLax-a-Day®17-34g/d($25-50/mo.)

Prokinetics Linaclotide(Constella®)290µg/d30minutesbeforebreakfast($160/mo.)Prucalopride(Resotran®)2mg/d,4weektrial($120/mo.)