[00:00:01] Speaker A: Thank you for listening to this latest episode of Ingest on ibs. If you are interested in this topic, join the Primary Care Society for Gastroenterology Power of the Microbiome webinar series, which covers helping patients with IBS. More
[email protected] UK events. Now over to Charlie Foreign.
[00:00:36] Speaker B: Welcome to Ingest, the podcast series designed for primary care and brought to you by the Primary Care Society for Gastroenterology. My name's Charlie Andrews, a GP with an extended role in gastroenterology based near Bath. It's my pleasure to host this podcast, which is an educational podcast designed to improve your learning and understanding of gastrointestinal conditions and presentations that we commonly come across in primary care.
On today's episode, I'm talking to Dr. Chris Black about IBS management. So irritable bowel syndrome management. This is part two in our IBS episodes. Part one being the episode I recorded with Anton Emmanuel looking at diagnosis of ibs. This is taking the story a step further and looking at management of ibs.
So, over the course of this episode we'll be discussing the different management approaches for IBS and we'll be looking at how to use the various medications and what other support or approaches we might take for helping patients manage their ibs. Just a quick note to start with. We have an episode on IBS dietary management and so we won't be discussing that in much detail during this episode. If you do want to listen to that one that's recorded with Marianne Williams in a previous episode and you can scroll back and find that one in our back catalogue. It's an episode I would highly recommend you have a listen to. Marianne is a really engaging speaker, really knowledgeable about ibs and we cover a range of topics going from first line dietary advice up to the low fodmaps, diet and things that we as primary care clinicians can do to help support people on that journey, we'll get into the episode. Now, I do want to apologize for the sound quality on this episode. Hopefully it doesn't detract from your enjoyment of the episode and the learning that you can get from Chris over the course of the next half an hour or so. So, here we go.
[00:02:40] Speaker C: So, Chris, thanks so much for joining me on Ingest. It's fantastic to have you here.
[00:02:45] Speaker D: Thanks for asking me, Charlie. It's a pleasure to be here.
[00:02:49] Speaker C: Chris, could you introduce yourself to the audience, please?
[00:02:52] Speaker D: Yeah, of course. So, I'm Chris Black. I'm a consultant gastroenterologist working in Leeds and I have Clinical and research interests in disorders of gut brain interaction and a particular focus on irritable bowel syndrome and been involved in the guidelines and lots of evidence synthesis that's relevant to our discussions about management today.
[00:03:14] Speaker C: Fantastic. And for our listeners out there, you'll know that we have part one of ibs, where I speak to Anton Emanuel about how we make the diagnosis of ibs, talking about some of the questions we should be asking, the investigations we should be doing. This second part is really to take the story further on and start to look at management.
And I first came across Chris at the BSG conference earlier this year and he was talking about a really interesting way of applying treatments to patients in a more sensible and more targeted way. And so hopefully we're going to be able to come onto that towards the end. Chris, talk about these clusters of patients where we can actually start to really make impact earlier on in their course of their condition.
And so I'm really excited to talk about that. But I thought to start with, we could begin at the point where the patient's been diagnosed with ibs. We where do you start when you've seen the patient and you've made formal diagnosis that this is a positive diagnosis of ibs, how do you take that patient on next? What's the next thing you would generally do here, Chris?
[00:04:23] Speaker D: So, I mean, some of this overlaps with what Anton was saying. I think it is really important that when we start the management process, we start with a clear explanation and checking the patient's understanding and being very, you know, being positive and affirmative about the diagnosis.
And part of that is explaining some of the things that patients may otherwise find a bit puzzling. So the fact that you've arrived at this diagnosis having done sensible tests, the results of those tests will be normal.
And I think we know as doctors that that's not a surprise. But from a patient's perspective, they may think that a normal test to simply means that the cause of the problem hasn't been found. So we need to be affirmative about that. We need to explain how it can be that symptoms can be arising in the absence of organic disease.
And we also need to gain an early understanding about the problems from the patient's perspective. So they may have a number of symptoms. Which of those symptoms is most troublesome for them? Is it abdominal pain? Is it their diarrhea? Is it their constipation? Is it a mixture of things?
And ask them a little bit about the impact that those symptoms are having on their daily life. We have to remember that management is biopsychostocial management. So we need to take a holistic point of view. I often say to patients that it's a little bit like trying to assemble a jigsaw puzzle. So we have lots of different types of treatments that we can use, but we know that no treatment is effective 100% of the time. Not all treatments are a good fit for all patients. And so when we're trying to plan what we might use first, we need to have an understanding about what problem we're trying to treat.
And that also helps us to ask the patient whether they have any particular concerns or questions themselves, that if we don't know about them, we may be sort of going down a treatment path and the patient may not actually like that. You know, some patients prefer, say, dietary management to drugs. Others may want a medication often, you know, we need to bring patients around to the idea that we will be combining these tools together to try and improve their symptoms and expectation management as well. I think at that early stage, because we certainly don't want to take hope away from patients. So we don't want to be saying, you know, we can't make you better, because that's not true. But if the end point is always seen as kind of total cure of symptoms, I would say that that's often not a very achievable endpoint for most patients with irritable bowel syndrome. Certainly some may recover completely. But bearing in mind that by the time we see patients, they may be telling us they've had these problems for five or ten years and have already tried things and still don't feel better, we may not be able to completely prevent the problem, but we can be very positive around the fact that we can add a layer of understanding to what's going on. We can validate their concern. So we should be saying, that sounds really hard. That must be really difficult, because many patients feel that if a test is normal, the doctor loses interest. So we also lose interest in the problem. We must listen to what's going on and say that we can improve the severity of symptoms. Often we can make them more manageable, and we can try to equip patients with some tools to make navigating those symptoms and the impact on their lives easier day to day.
[00:07:50] Speaker C: I think it's really helpful when you think about trying to understand how this is impacting them and what their priorities are. It's really important that we keep that at the forefront when we're thinking about management and when you move on to starting to Manage the patient and provide sort of first line treatments. Where do you go, Chris? What sort of things would you recommend using for the different symptoms that people can experience?
[00:08:14] Speaker D: So diet is important and I won't go into the detail of dietary management because I know that you've spoken about that before, but I think it's worth pointing out that 80, 90% of people who have irritable bowel syndrome will identify in their own mind that what they're eating is part of the problem.
And so I think, you know, simple things we can do. We can direct patients to traditional dietary advice through the British Dietetic association or through nice, which provide some generic concepts about diet and managing IBS symptoms and also provide some symptom specific advice. So there's advice in there for changes that might more help diarrhea and urgency changes that might be more tailored to bloating and those that may be more tailored to constipation.
And, you know, if patients need or want more specialist input, then referring them to see a dietitian is helpful. And I think most patients can get some benefit from diet. The one thing I would say is that my experience is that symptoms are often more related to eating than they necessarily are related to specific dietary components. Some patients do of course, get benefit from excluding specific things from the diet, the low fodmap diet being an example.
But more often than not, patients will experience that eating sets their symptoms off. And this is why they will frequently say, I ate such and such a type of food and I was fine and then I ate it again and I wasn't fine.
And that's very confusing for patients because then they think, well, I mustn't eat that ever again. And their diet can become very restrictive. So sometimes pointing out that it's more not what they were eating, but just that in that moment eating a meal seemed to sort of set the symptoms off and seem to trigger the symptoms can be helpful. So a little bit of dietary discussion, some simple dietary advice is helpful. Fiber is probably a more specific thing that's worth covering. And so I think talking about fibre intake with patients is helpful. Conventionally, we often think about that, you know, to do with constipation in the main.
And the emphasis with respect to fibre should largely be on soluble fibre. So things like hispagula some role for increasing linseeds, for example, insoluble fibre. So stuff like bran tends to just add a lot of bulk to people's stools. It doesn't bring a lot of water along with it. And so People can actually find that when they increase that sort of fiber, they might feel worse.
And also, if patients are trying to increase fibre in their diet, you should advise them to do it in a gradual way. So don't go from very little to lots because your gut will struggle to accommodate that. So some discussion about diet, I think, is helpful for all patients. And then in terms of medication, I would think about directing that according to the patient's predominant symptom. And that's why it's helpful, I think, to ask them about pain versus diarrhea versus constipation.
Perhaps, you know, maybe we should look at. We could think about pain first, Charlie.
[00:11:16] Speaker C: Yeah, yeah, could we do that and thinking, you know, about different antispasmodics and kind of. Which you'd recommend and things. Because pain is one of the sort of key things that patients talk to us about is they get bloating and pain and how do they manage that?
[00:11:30] Speaker D: Yeah.
So there are a number of drugs that are available to manage that sort of first line. And as you've said, they tend to be antispasmodic drugs.
The slight problem with some of the evidence around that is that a lot of the studies of those drugs are quite old. But when you look at the results of those trials, there does seem to be a general benefit in favour of treating pain with antispasmodics. And this is based obviously on the fact that we think that pain mechanisms relate to spasm of the gut, hypersensitivity of the gut, etc.
Of all of the antispasmodic drugs that are available, my personal preference is to use hyocim, so buscapan. I think that that is probably one of the more effective drugs. Certainly when we look at the evidence, it comes out as being one of the more effective drugs. So using hyacinth, 10 to 20 milligrams, three or four times a day is a helpful strategy. I don't personally find me Beveran very helpful. I know that it gets used a lot.
There's not a lot of evidence to underpin it and the evidence that exists is relatively poor. But again, it does work for some people. So I think using antispasmodics, discussing with patients why we might use them, trying one, changing to another if it's not effective is reasonable. Peppermint oil is the other option.
The older trials of peppermint oil are all pretty positive. There have been some newer, bigger and more rigorous trials of over the last few years that are not so good. So the results of those are not so impressive. I think there's still a role for using Pepimetol, but I do wonder whether maybe it's not quite as effective as we thought it was. But I still find many patients like it and I think that it can appeal to patients who want, who need something for pain, who perhaps don't like the idea of taking a drug based therapy because it's obviously a natural based substance. So peppermint oil for pain as well is helpful. So first line, those are the sorts of things that I would be using.
[00:13:33] Speaker C: And if we think about the bowel disturbance and the sort of things that you might consider. So in a patient with diarrhea, predominant irritable bowel syndrome symptoms, where would you go for that?
[00:13:46] Speaker D: I mean, diarrhoea is a really difficult symptom to treat, unfortunately, because the range of options that we have is relatively poor and the symptom can obviously be very debilitating for patients. Antidiarrheal drugs. So loperamide is still a good option and can be used as a first line treatment. And the advantage of that to some extent is that it gives patients a bit of control about when they take it, how much they take. Some people will find benefit from taking it regularly, other people may prefer to use it to help to control symptoms in circumstances where they might be more concerned about the availability of toilet facilities. And if they're traveling or they're going out somewhere, it is recognised that patient satisfaction with the use of that drug may be a little low, partly because I think it sometimes causes side effects. So, you know, slowing the gut down. So sometimes people bloatually gets worse or it might flip someone into being constipated for a bit.
So that can be challenging. But it is still a useful strategy and one that I think using first line can be helpful.
There are some other options available.
So there was a big study of something called ntrusgel, which was done by Jan Yanikow and colleagues, showing that that can be an effective treatment for diarrhea in ibs. So Entrust gel is what's called an enteral absorbent. So it's a drug that probably thickens the intestinal contents and is said to kind of bind certain substances within the gut that might contribute to diarrhea. It was originally used as a treatment for kind of travelers diarrhea, but it does seem effective in IBS at the moment. The problem is that it's not a drug, it's classed as a device and it's not prescribable for most people. So it's something that patients can obtain, but I don't think it's yet available on formulary for most practitioners, but it's something to be aware of as an option for patients.
And fibre can have a role. So high doses of fibre, probably not a good idea in diarrhoea, but an increase to some extent in fibre because it bulks up the intestinal contents that can sometimes be helpful in managing diarrheal symptoms. So, first line, I think those are the sorts of treatments that would be available.
[00:16:15] Speaker C: And can I just go back to the paramide, because this is one that we give quite a lot in primary care. How much loperamide can one give, for example, and how would you guide someone in the use of it who's got ibs?
[00:16:27] Speaker D: Yeah, so I generally tell patients to start with low doses, so taking 2mg once or twice a day, but more often than that. So some, you know, some patients will take it three or four times a day and we might need to increase the dose. So I have some, you know, I have patients who take 8 milligrams of loperamide four times a day.
It's very variable. And I think that this is one of the difficulties sometimes of managing IBS symptoms is that there isn't a single approach that's effective for everybody. And I generally think that with. With most drug therapies, starting at a more moderate dose and advising the patient to titrate the dose, depending how they respond and how they feel, is a perfectly appropriate strategy. And if they experience side effects, reducing the dose again is reasonable. But I do think that using it regularly is fine. So if patients need to use it regularly to gain control of their symptoms, that strategy is okay, and I would encourage that.
[00:17:35] Speaker C: Brilliant. And then looking just at the constipation side, which medication would you approach? We talked a little bit about diet. There. Are there other things that you would be recommending to patients?
[00:17:46] Speaker D: Well, constipation, Charlie. Yeah. So laxatives obviously are used widely as the first line treatment for constipation. Perfectly reasonable. Most of them are very safe.
Specifically, there's nothing, actually a lot of evidence for using laxatives in ibs. So there are very few trials. The only two trials are small trials of polyethylene glycol. So things like, for example, which shows some benefit. But, I mean, IBS is sort of on a spectrum with chronic constipation. The difference is just that IBS C is a more painful disorder than chronic constipation. Is. So I think it's quite reasonable to extrapolate the much bigger body of evidence from constipation to ibs. So I think using laxatives of various different kinds is sensible. I tend to prefer osmotic laxatives. So things like movicol, I think you have to be a little bit careful with stimulant laxatives. They can be helpful, but of course, they are encouraging the bowel to contract. So if patients are getting spasm and pain, giving them something like senna may actually, you know, may find that that makes their symptoms, symptoms worse.
You know, one of the advantages of using things like movicol is that you can take smaller doses than even a whole sachet. So it's not unusual that I might tell patients to start with, you know, just half a sachet at a time and again titrate the dose, depending how they feel their symptoms respond. But very reasonable to use laxatives. And for many patients, you know, they will get some degree of relief from that. The only distinction, perhaps, is that when we're talking about constipation symptoms, it's important to assess in the history whether there's an element of dysentergic defecation. So, in other words, are patients actually struggling with the process of going to the toilet? You know, some patients will say, well, this has loosened my stools up, but I still find it difficult to go. And so. And so that implies that there's an evacuatory problem, you know, more sort of pelvic floor coordination problem, and that might need a different, you know, different sort of approach than just using medication.
So if laxatives are not working, it's worth exploring the history a little bit more to understand whether there are other elements that might be impacting that reason.
[00:20:07] Speaker C: So we've looked at some of the first line sort of treatments that we should be thinking about to try and help manage those symptoms. It's not uncommon for patients to find that that's just not completely solving their problem.
Could you talk a bit about some of the second line treatments and other things that we could be considering here?
[00:20:25] Speaker D: Yeah, sure, Charlie. So we'll take everything in the same order again. So if we go back to pain, so if patients have an inadequate response to antispasmodics, then we should be looking at neuromodulator drugs. So these are, of course, drugs that are classically antidepressants, but are used often at lower doses than we would use to treat mood disorders, to treat pain. And this is Obviously, on the basis that these drugs may help to desensitize some of the signaling between the gut and the brain, first and foremost, there would be tricyclic antidepressants. So the use of drugs like amitriptyline or nortriptyline. And helpfully from a primary care perspective, the Atlantis trial, which was published last year in the Lancet, that was a very large trial of using titrated low dose amitriptyline in a primary care setting, which showed that the use of that drug for pain in IBS was that it was effective.
So, so starting with those drugs at low doses, so typically 10 milligrams of amtriptyline taken at nighttime, because obviously it can cause drowsiness and then titrated, depending on how the patient feels, their symptoms are responding. And typically you don't need to go above doses of 30-50mg. Sometimes patients might need a higher dose, but in IBS generally it would be lower doses that would be effective.
There is some evidence for using SSRIs, but they don't seem to be as effective. So they're not as good drugs for treating abdominal pain.
However, they can be helpful, particularly if patients have concomitant mood disorders or anxiety. So if we think that low mood or anxiety is part of problem driving symptoms, using a drug like an SSRI might actually be helpful in that setting.
Snris. So drugs like duloxetine, they do have some evidence for use in other chronic painful disorders like fibromyalgia. There is a lack of evidence in ibs, and it would be nice to see some trials that are done to address that. But I do use duloxetine quite often to treat pain in ibs, particularly if people have tried tricyclics and just not got on well with them with side effects, for example. And so they probably start with 30 milligrams of duloxetine, can go up to 60 milligrams, and it is an effective strategy for pain. So those are the two neuromodulator drugs that I think are most useful in managing IBS, with SSRIs playing the part. In secondary care particularly, we may augment one neuromodulator with another. So that means use them in combination. So I may see patients who are already on an ssri, like sertraline, for example, because it's been started for anxiety or low mood, and I wouldn't be afraid of starting them on a low dose tricyclic alongside that. We would warn patients about theoretical risks of serotonin syndrome, for example, but with low doses of amitriptyline, I've never seen that happen. And it can be useful to, you know, if they've still got pain despite being on their surgery, which might otherwise be managing their anxiety very well. I would add in a little bit of amitriptyline and that that can be helpful for patients with more severe or refractory symptoms. Personally, I would avoid or try to avoid the use of things like pregabalin or gabapentin. It can be helpful, but there are some genuine legitimate concerns about dependency issues with things like pregabalin. So it can be useful, but it wouldn't be something that I would be using first line. And it requires a bit of careful thought and discussion before taking that approach.
[00:24:05] Speaker C: And is there a role for psychological therapies here as well?
[00:24:10] Speaker D: Yeah, so brain, gut, behavioral therapies. So things like cognitive behavioral therapy, gut directed hypnotherapy? Yes, absolutely. And they are. It's important to remember that those sorts of therapies are designed to treat symptoms in ibs, so they're designed to treat bowel problems and pain and to address and explore some of the links between thoughts and behaviour and those symptoms. So the way that those symptoms might lead to avoidant behaviours or fear etc. They are primarily treatments for psychological symptoms per se.
And yes, they are effective. So there are many studies showing that they can be useful. We have recently published a network meta analysis looking at their role specifically for abdominal pain and finding that there is evidence that they can address pain, so where available, they can be helpful. The problem is that access to psychological therapies can be poor. It's a definite area of unmet need. And I think that's why conventionally, guidelines have often positioned them as a sort of last resort. And probably when we come on to talk about more integrated approaches to treatment, actually for many patients, using these tools at an earlier stage alongside some of the other approaches probably is more. More useful. There are several apps that have been developed that are designed to deliver these sorts of therapies to patients without the need for a therapist. There are also trials of things like telephone, cbt, minimal contact approaches that have shown that they are effective and that those effects persist. So there are routes to achieving better access. And I hope that that's an area that we see some further development and funding in to make these treatments more available, because at the moment, patients would need to do that sort of thing at their own cost. But, yes, they are Valid and useful approaches for managing pain as well as other symptoms. Charlie, Great.
[00:26:10] Speaker C: That's really helpful to know. And you're right, it is quite hard to access some of these services, but it sounds like they certainly could have a role. Chris, I just wanted to, before we start talking about a more integrated approach that you've looked into and that you're going to talk to us about, I thought maybe we could just think about referrals to secondary care. So what sort of patients do you generally see coming into secondary care from primary care with the IBS label? You know, in primary care, we often are looking after patients who've got very difficult symptoms in some cases, and, you know, we may be struggling to work out where to go next. Are these the sort of patients that you see and what sort of things might you do differently in secondary care that perhaps we could think about?
[00:26:56] Speaker D: Yeah, so I think, I mean, it's important to emphasize that the majority of patients with IBS are managed by gps. You know, gps have a lot of experience and expertise in that field, so I'm not seeing the majority of patients. I think there's probably. There's two main reasons, I think, why patients get referred to secondary care. One is where there's diagnostic doubt, and that may not be on the part of the gp, but it may be that the patient just feels that they're not, you know, they're not happy with the diagnosis or they're concerned that something's been missed.
The other is obviously where treatment has been tried appropriately and patients have not responded well or are having ongoing problems or have very difficult refractory symptoms. So those are probably the two main groups of patients that you see. And, you know, some of the management is simply the fact that they're then seeing a gastroenterologist. It doesn't mean that you're necessarily giving a different message or taking a different approach. There's just some validity in the fact that you're seen as a specialist person in that area, rather than the gp, who is often taking a more general view of anything, which is not a criticism of anybody. It's just, I think that's just somehow, you know, the way that things come across.
And I think the approach that we would take is similar in the sense that we try to identify what the fundamental problem is and we try to direct treatment at it. We do use some other approaches, you know, so we'd be more confident with certain second line treatments, the use of certain neuromodulator drugs, for example, starting those maybe earlier or Changing to different approaches. If they've already tried something for diarrhea, for example, you know, second line drug options are limited in the uk, but something that I do use quite a lot of is Ondansetron. So ondansetron is a 5HT3 receptor blocking drug which is similar to drugs that are available in other countries. So in the States they have Alocitron, Japan they have Remocition, but they're not available in Europe. Ondansetron, obviously widely available drug, has been looked at in three trials. Shown to be beneficial for stool consistency, not so much for pain really, but good treatment for diarrhea. So I do use Ondansetron to manage diarrhea, starting usually about 4 milligrams, titrating the dose. Again response very variable, but it's a useful tool.
The other thing that I probably look for quite a lot is bile acid diarrhea. So primary bile acid diarrhea, where patients still have an intact digestive system, is relatively common in people who meet criteria for IBSD. So about 25 to 30% of patients may actually have bile acid diarrhea. So I'm a proponent for testing for that. I like using CCAT scans to look for it. I think where it's at the milder spectrum, it may not be the main driver of patient symptoms, but uncover more severe bile acid diarrhea, it may be an important mechanism in driving symptoms. And of course that then takes us down the route of using bile acid sequestrants. So things like cholestyramine or Colacevolam to manage that. And you can get some very good results from doing that. I know some people don't have access to those tests or might favour doing therapeutic trials, but there is some evidence that that doesn't work that well, particularly if patients get side effects to taking a bile acid secretion. They may give up on that line of inquiry, but it still might be the diagnosis. So I think looking for that is something that maybe we do in secondary care with constipation. If laxatives haven't been effective, then some second line drugs there. So linaclutide, which is a secretagogue drug, so a drug that does two things really encourages electrolyte and water movement into the intestinal contents, has some transit accelerating role. It is a good drug, it is effective.
The problem that we have here is that we only have the high dose for some reason, I don't know why, so we just have 290microgram dose. In other countries you can get formulations that are lower doses, 145 micrograms, for example, and for some patients, it's just a bit too effective. And I would often like to be able to reduce the dose, but I can't. I can only reduce the frequency. But I do use the naptatide, prucalopride, which has been tested a lot in chronic constipation. That's a serotonin agonist, has not been studied in trials in ibs, but I do use it in IBS for the reasons that I alluded to earlier, which is that there's clearly a sort of continuum between chronic constipation and irritable bowel syndrome. So those are the sorts of drugs that I might reach for.
And I also have a little think about the pelvic floor dysfunction. So I have some ability to refer to community services for biofeedback, pelvic floor physiotherapy. And some patients get a lot of benefit from using irrigation devices, so transanal irrigation, if they're having a lot of problems with straining, to reduce that, if drugs haven't been effective. So those are some of the things that we might think about specifically for predominant symptoms.
[00:32:11] Speaker C: Brilliant. Thank you. So we've gone through this in quite a sort of conventional way, I think, Chris, and we've looked at kind of first line, second line.
I'd now quite like you to explode all of that with your.
With. With your new concept of a more integrated approach to management. Do you want to talk about that? Because I think it's. When I heard it first, it was a real light bulb moment and it made me think, you know, the linear approach to things actually perhaps is not going to fit every single patient. So I'm going to hand over to you, Chris, because I really want to hear about your approach that you've created and been working on, really, for the last few years, I believe.
[00:32:49] Speaker D: Yeah. Thanks, Charlie. So this has been an area of research interest for us recently and I think that, you know, it's well recognized that IBS is a very heterogeneous condition. So we're basically, you know, we're diagnosing patients based on a certain pattern of symptoms, but almost certainly the cause of those symptoms is probably not the same in all of those different patients, even if they have quite similar symptoms. It's also recognised that things like psychological health play a part in driving symptoms. They're not the cause of symptoms, but they are part of the puzzle. And so this has taken us down a route of looking at whether we can subgroup People differently. So conventionally, as we've been discussing, people are kind of subgrouped based on whether they have diarrhea or constipation or a mixture of those things. And that is kind of drive treatment choices. But there's an increasing recognition of the need to maybe take a more integrated approach and expert consensus. People like the Rome foundation, who diagnose or set the criteria for ibs, they have suggested doing this on a per patient level, which I think is what we all do in a consultation. We try to understand the patient in front of us, but we were interested to see whether we could do this in a more systematic way. So, in other words, whether we could subgroup people using factors beyond GI symptoms and then look at whether we can use that to explore their symptoms. And other groups have done the same thing. And generally the theme that emerges is that if we use a combination of bowel symptoms, abdominal pain and psychological health status in terms of mood and somatisation, we can put patients into specific subgroups and we see these clusters emerging in different cohorts done in slightly different ways. So that's quite encouraging because it suggests that, I mean, it's not necessarily surprising because we know that psychological health is important, but what's important about it is the fact that it shows that actually these are factors that separate people at a group sort of level, not just at an individual level. So we found, for example, that there were were groups of patients that predominantly have quite low overall symptom severity. They don't particularly have a lot of psychological comorbidity. And those are probably the patients that we see where we explain a little bit to them. We might give them some first line therapy and they may be the ones that we feel respond pretty well to that. You know, they're better, they manage their symptoms pretty well, they may not need to come and see the doctor very much. There's a similar group who have relatively low symptom burden but do have psychological health problems. And there, you know, that's probably where we may be better to be using brain gut therapies at an earlier stage, because those patients maybe don't need so much drug treatment for their bowel symptoms or their pain, but they may benefit from early use of psychological behavioural therapies. And then we see patterns where, you know, diarrhea predominates, but there's little in the way of psychological symptoms. And the converse is true. So diarrhea predominates with pain and there's lots of psychological symptoms. And so again, the group with less pain and Less psychology may be the ones that are more likely to respond to simpler measures, to first line measures. Whereas those with more complex symptoms, more severe symptoms, probably need a more integrated approach. So they may need, you know, drug earlier, use of a neuromodulator and possibly, you know, psychological therapy as well. The same is true of constipation. So you see the same pattern. There's. And then there's a group of patients that have very, very severe symptoms, really across the spectrum. And they're probably the patients that are quite refractory to treatment and that are a struggle to manage in primary care. They're probably some of the patients that I see in my sort of more specialist clinic who again need kind of earlier, more integrated approach.
There is a trial that was done in Australia called the Mantra Study, so by Nick Talley's group in Australia that looked at comparing kind of standard approach. This was in a secondary care setting, but looked at standard care versus this sort of integrated approach where they had a psychologist and a dietitian and a gastroenterologist, all kind of seeing patients. And when you take an integrated approach in that setting, the outcomes were better. So patients symptoms improved more quickly, they needed fewer follow ups, etc. So I think by looking at this sort of subgrouping, we can start to try to make a case for saying that we should be personalizing care more. There's an element of that always, you know, in the individual interaction with the patient. But I think the advantage of this sort of system is that it perhaps enables us to open this opportunity up to practitioners more generally. So it's not relying on your own expertise or interest, it's providing you with a tool that may help you to direct the patient's therapy, regardless of kind of taking that point of view. It's something that we are looking at trying to test out a little bit more systematically, because that's important. It's a theory at the moment, one that does seem to have a weight and an importance, but it's something that we want to try to test more systematically with patients.
[00:38:13] Speaker C: It seems that the history is key really, isn't it? It really goes back to really understanding the symptoms that the patient has the impact on their life. And actually having a proper holistic approach to that patient feels like that sort of lies at the heart of a lot of what you're talking about there.
[00:38:29] Speaker D: Yes, I think that's right. And also trying to identify where there are psychological health needs in the consultation. And that can be difficult to do, I think, because sometimes we Just don't have a lot of time. I mean, gps particularly don't have much time in consultations to identify things. And continuity in general practice is much more difficult than it used to be. So patients may see one person and then see a different doctor, possibly even each time they go to the practice. And I think that presents a unique challenge, but trying to find the time to ask a little bit about mood, about stress, about anxiety, and to do that in a way that makes it clear that you're not pejoratively suggesting that the symptoms are all in the patient's head. You know, this goes back to what Anton was talking about. You know, these are two things that coexist. Not. It's not an either or situation. But, yeah, digging into the patient's personal experience of their symptoms is important in terms of being able to understand for them what pattern of symptoms, both GI and non gi, are relevant and direct them to treatment. I mean, the advantage of the subgrouping work that we've done is that this is a. It's a model. So if you could design a system where you could get patients to answer the limited range of questions, you would actually be able to put them into that group. So, you know, if you, if they answered a series of questions about their gut symptoms, about their mood, etcetera, you could, you could assign them to a cluster, for example. And that's sort of the work that we want to do in a. In a treatment way, if we can, to test whether treatment by that approach is better than just doing kind of what the doctor might otherwise choose to do on an individual level.
[00:40:15] Speaker C: I think it's really exciting, Chris, and this sort of tailoring of the treatment is really, I think it's fascinating and I'm really looking forward to seeing where that goes. So I'll be keeping an eye out for your progress on that. Chris, we're coming up to the end of the episode now, and this is the time when I give the speakers an opportunity to kind of Final messages. Key take homes for our audience. Do you want to just give us a few key take homes from management of IBS for us today?
[00:40:43] Speaker D: Yeah, sure, Charlie. So I think it starts with being confident about the diagnosis and giving an explanation about why these symptoms are arising, asking the patients about their holistic experience of their symptoms, so not just what symptoms they have, but try to understand the impact and also ask them what are the most important symptoms, because there are usually multiple symptoms. And so when you're trying to choose what treatment to start with, it's Helpful to know what's the biggest problem for the patient and adjusting expectations a little bit about what we might be able to achieve with treatment. And then from a first line perspective, I think most patients want and benefit from some form of dietary advice and then taking an approach where we direct first line treatment towards the biggest problem. So antispasmodics or pepimentol, first line for pain, antidiarrheal drugs, first line for diarrhea, laxatives for constipation.
And also for GPs to feel more confident perhaps about using low dose amitriptyline. There's an evidence base for that now. So neuromodulators are helpful for the second line management of pain where that doesn't respond to antispasmodics. And then referring to someone like me, if the patient has symptoms that are more difficult to manage or if they need to access a therapy that the DPS can't give, and I might use second line drugs, constipation or diarrhea have some better links with psychological therapy and specialist dietary and violet. So it's an integrated approach, but recognising that many patients are very well managed with some of Those more simple first line treatments by GPs up and down the country.
[00:42:27] Speaker C: Brilliant. Thanks very much, Chris. That's a great note to finish on. It's been a pleasure talking to you today. I've learned loads and really enjoyed exploring all the different aspects and also talking about the work that you're doing I think is really fascinating. So thank you so much for joining me today.
[00:42:43] Speaker D: Thanks, John. It's been a pleasure.
[00:42:47] Speaker B: There was a huge amount of really useful information in that episode. I really enjoyed discussing this with Chris and looking at the different approaches to managing ibs.
Some of the take homes I took with it, we want to make sure we've got that really secure diagnosis as our very initial starting point with management. Try and help the patient understand why they're experiencing symptoms. Secondly, it's to really validate their experience and also to manage their expectations around management.
We looked at the various conventional management pathways here. So we talked about the dietary advice, we looked at pharmacological treatments. One thing that stood out there was really the use of neuromodulators, something that perhaps in primary care we're a bit more reluctant to use, but perhaps something that we should be thinking about more commonly. Things like low dose amitriptyline being particularly effective at helping to manage those more difficult IBS symptoms. Chris also talked about his slightly more integrated approach with different clusters of patients and symptoms to try and help us to sort of tailor that approach to IBS management. So not simply looking at it a formulaic, sort of more conventional pathway, but really thinking about what is it that is going on with this patient and their symptoms, how am I going to help manage that most effectively? And it might mean bringing those psychological therapies higher up our treatment pathway, or it might mean actually focusing more on the symptom management. So we've looked at all of this today. It's been fascinating. I really hope you've enjoyed this episode. If you want to get updates whenever we bring out new episodes, please please do. Just click subscribe and then you will get a notification. Whenever we do that, we always appreciate any feedback, any comments. So if you want to get in touch with the Primary Care Society for Gastroenterology, please do. Or you can leave reviews here on whatever podcast platform that you use to listen to this episode.
So finally, thank you so much for listening. I really hope you've picked up a few nuggets of information that will really enhance your experience and knowledge around this topic and things that you might be able to take and use in your primary care setting. Thank you very much.
