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CME: An Update on Managing IBS & Chronic Idiopathic Constipation

CME: An Update on Managing IBS & Chronic Idiopathic Constipation
Author Information (click to view)

Eamonn M.M. Quigley, MD, FACG

Chief, Division of Gastroenterology and Hepatology
David M. Underwood Chair of Medicine in Digestive Disorders
Houston Methodist Hospital
Professor of Medicine
Weill Cornell Medical College

Eamonn M.M. Quigley, MD, FACG, has indicated to Physician’s Weekly that he has worked as a consultant for Salix, Almirall, Ironwood/Forest, and Shire/Movetis and as a paid speaker for Janssen, Procter and Gamble, Alimentary Health, Almirall, and Shire. He is also a shareholder of Alimentary Health and has received grants/research aid from Vibrant, Rhythm, Norgine, Procter and Gamble, and Alimentary Health.

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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Describe key recommendations and updates to the American College of Gastroenterology’s 2014 monograph on the management of irritable bowel syndrome and chronic idiopathic constipation.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwjune3.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria, Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Eamonn M.M. Quigley, MD, FACG
Dr. Quigley has disclosed the following relevant financial relationships:
Consultant:  Almirall, Ironwood/Forest, Salix Pharmaceuticals Inc., Shire/Movetis NV
Paid Speaker:  Alimentary Health Ltd., Almirall, Janssen Pharmaceuticals Inc., Procter and Gamble Co., Shire
Shareholder:  Alimentary Health Ltd.
Grants/Research Aid:  Alimentary Health Ltd., Norgine Pharmaceuticals Ltd., Procter and Gamble Co., 
Rhythm Pharmaceuticals, Vibrant Pharmaceuticals Inc.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Eamonn M.M. Quigley, MD, FACG (click to view)

Eamonn M.M. Quigley, MD, FACG

Chief, Division of Gastroenterology and Hepatology
David M. Underwood Chair of Medicine in Digestive Disorders
Houston Methodist Hospital
Professor of Medicine
Weill Cornell Medical College

Eamonn M.M. Quigley, MD, FACG, has indicated to Physician’s Weekly that he has worked as a consultant for Salix, Almirall, Ironwood/Forest, and Shire/Movetis and as a paid speaker for Janssen, Procter and Gamble, Alimentary Health, Almirall, and Shire. He is also a shareholder of Alimentary Health and has received grants/research aid from Vibrant, Rhythm, Norgine, Procter and Gamble, and Alimentary Health.

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The American College of Gastroenterology has released an updated monograph on the management of IBS and chronic idiopathic constipation. The monograph also uses recent scientific evidence to shed light on traditional interventions.
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IBS and chronic idiopathic constipation (CIC) are among the most common functional gastrointestinal (GI) disorders, with studies estimating that between 5% and 15% of the general population experiences IBS symptoms, whereas CIC symptoms occur in about 14% of people. Recently, the American College of Gastroenterology (ACG) released a monograph—published in the American Journal of Gastroenterology—that updated prior monographs on approaches to treating IBS and CIC.

To develop the monograph, the ACG’s Institute for Clinical Research & Education conducted a systematic review and meta-analysis of randomized clinical trials that assessed several types of interventions for IBS and CIC. “We looked back at previous monographs from recent years,” explains Eamonn M.M. Quigley, MD, FACG, a co-author of the update. “The last monograph on constipation came out in 2005, whereas the last one on IBS was released in 2009. Since then, there have been significant developments that warranted an update.”

Diet & Fiber

An important addition to the ACG guidelines is new information on the relationship between diet and IBS (Table 1). “Research has shown that diet has emerged as a major issue, especially for patients with IBS,” says Dr. Quigley. “This isn’t new for patients because they’ve known for years about certain foods upsetting their GI tract. For clinicians, however, we now have good evidence that diet is a major factor in the precipitation of IBS attacks.”

Update-Managing-IBS-CIC-Callout

The guidelines note that specialized diets may improve IBS symptoms for some, but the recommendation was labeled as weak because of a low quality of evidence. Current data show that gluten-free diets and diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—also known as the low FODMAPs diet—are promising, but their precise role in the management of IBS needs to be better defined. “We have collected evidence supporting that certain diets appear to be helpful in managing IBS,” says Dr. Quigley. “However, more studies are needed on gluten-free diets and other diet strategies to optimize outcomes.”

Dr. Quigley says research is also needed to further explore the role of fiber in both IBS and CIC. “When managing IBS, patients need to be careful with fiber because it can actually make some cases worse,” he says. “The evidence on fiber for CIC also isn’t strong.” The guidelines note that people with CIC should slowly increase fiber intake because it may help with symptoms (Table 2). Patients with IBS should be more cautious due to potential problems with bloating.

Drug Therapy

According to the ACG monograph, some new medications have reached the market and may be helpful for managing IBS and CIC. Some of these drugs only act in the GI tract and do not need to be absorbed into the bloodstream in order to be effective. The monograph gave a strong recommendation for linaclotide as a treatment for both IBS and CIC, citing high quality of evidence for both conditions. Lubiprostone also received a strong recommendation for IBS and CIC, but the quality of evidence was characterized as moderate for IBS and high for CIC. “Both of these medications seem to be effective for each of these disorders,” Dr. Quigley says.

The evidence on prebiotics and synbiotics was classified as very low, and the ACG guidelines gave these therapies a weak recommendation for IBS. However, the writing group did note that, overall, probiotics appear to improve global symptoms, bloating, and flatulence in IBS. They also noted that probiotics generally seemed to have beneficial effects in IBS.

Other Helpful Recommendations

The ACG monograph also provides clinicians with recommendations on other more traditional treatments, including the use of antidepressants, antibiotics, serotonergic agents, and psychological therapies. “Many of these treatments can help to some extent, but some will be more helpful than others,” Dr. Quigley says. “It should be noted that many of these traditional treatments were developed before controlled clinical trials became more rigorous with regard to their performance and analysis. We don’t have a lot of high-quality evidence to support them, but these treatments may still help patients with IBS and CIC.”

Dr. Quigley anticipates that future research will garner more data on diets that may improve IBS and CIC symptoms and further establish the role of fiber for these patients. “More data are also needed on emerging drug therapies that are currently in the early phases of development,” he says. “Several treatments are being investigated for IBS and CIC and appear to be promising. As data emerge, the hope is that we’ll have more treatment options at our disposal so that we can decrease the burden of these conditions.”

Readings & Resources (click to view)

Ford AC, Moayyedi P, Lacy BE, et al; for the Task Force on the Management of Functional Bowel Disorders. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol. 2014;109:S2-S26. Available at: http://gi.org/wp-content/uploads/2014/08/IBS_CIC_Monograph_AJG_Aug_2014.pdf.

Quigley EM, Abdel-Hamid H, Barbara G, et al. A global perspective on irritable bowel syndrome: a consensus statement of the World Gastroenterology Organisation Summit Task Force on Irritable Bowel Syndrome. J Clin Gastroenterol. 2012;46:356-366 .

Lovell RM, Ford AC. Global prevalence of, and risk factors for, irritable bowel syndrome: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10:712-721 .

Koloski NA, Jones M, Wai R, et al. Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women. Am J Gastroenterol. 2013;108:1152-1158 .

Belsey J, Greenfield S, Candy D, et al. Systematic review: impact of constipation on quality of life in adults and children. Aliment Pharmacol Ther. 2010;31:938-949 .

Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011;106:1582-1591 .

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