Thread by @john_damianosMD

Recapping @AmCollegeGastro's #VirtualGrandRounds on #IBS! Let's begin!
🟣IBS can be diagnosed with the Rome criteria
🟣Making a positive diagnosis is very helpful to patients, many of whom have gone years without a name for their symptoms

#IBS is heterogeneous, and so are its pathogenesis and pathophysiology.
🟣Identifying underlying factors in patients can help target treatment!

@AmCollegeGastro

Important principles when diagnosing and treating #IBS.

@AmCollegeGastro

Excess and unnecessary testing is often performed in #IBS, to the detriment of patient and provider. A more rational approach to testing:

@AmCollegeGastro

Lifestyle modification is first-line in the treatment of #IBS.
🟣Reduction of stress (therapy, meditation, #hypnosis, #yoga)
🟣#exercise
🟣#sleep hygiene
🟣eliminate alcohol and #smoking
🟣#diet (best done in conjunction w RD)

@AmCollegeGastro

Dietary management of #IBS
🟣low-FODMAP diet has the most data for improving symptoms
🤢FODMAPS⬆️IBS symptoms from gas production in pts w visceral hypersensitivity
🟣#gluten-free helps some IBS-D patients, but they may actually have non-celiac gluten sensitivity
@AmCollegeGastro

Both low-FODMAP and mNICE diets have data for improving #IBS symptoms.

@AmCollegeGastro

Pharmacologic treatment of #IBS should be driven by the most distressing symptom.

OTC options include:
🟣antidiarrheals: loperamide, clay binders
🟣anti-spasmodics
🟣peppermint oil
🟣#probiotics

@AmCollegeGastro

Many agents commonly used in #IBS do not have much good evidence!

@AmCollegeGastro

Peppermint oil has some data for #pain in #IBS. Enteric coated is best to avoid exacerbation of #GERD.
🟣NNT=4!

@AmCollegeGastro

#Probiotics have some data for #IBS, but the strain is important. [Side note: head over to @aeprobio for evidence-based recommendations!]
🟣NNT=7 (class effect, likely larger with appropriate strain specificity)

@AmCollegeGastro

FDA approved therapies for #IBS-D:
🟣rifaximin
🟣euladoxine
🟣alosetron

@AmCollegeGastro

The efficacy of rifaximin in #IBS-D was demonstrated in TARGET 1-3.

@AmCollegeGastro

Evidence for euladoxine in #IBS-D.

@AmCollegeGastro

Data for alosetron in #IBS-D.

@AmCollegeGastro

Antidepressants/neuromodulators have good data for #IBS, with TCAs having the strongest data. Use side effects to your advantage!

@AmCollegeGastro

Bulking agents are recommended in #IBS-C, but the evidence is weak.

@AmCollegeGastro

FDA approved therapies for #IBS-C.
🟣linaclotide
🟣plecanatide
🟣lubiprostone
🟣tegaserod
🟣tenapanor

@AmCollegeGastro

Evidence of linaclotide for #IBS-C.

@AmCollegeGastro

Evidence for plecanatide, lubiprostone, tegaserod, and tenapanor in #IBS-C.

@AmCollegeGastro

No increased risk of MACE with tegaserod as previously thought.

@AmCollegeGastro

Reached the thread limit- see next tweet for the rest!!!

@AmCollegeGastro #virtualgrandrounds #IBS #GITwitter #GI #gut #microbiome #FGID #DBGI #motility

Research into therapies for #IBS is rapidly expanding. Here are some of the candidate agents and pathways ⬇️⬇️⬇️

@AmCollegeGastro

Bile acid malabsorption is very common in #IBS-D. Bile acid sequestrants are a potential therapy to treat the diarrhea.

@AmCollegeGastro #motility

Ramosetron is a serotonergic agent that has decent preliminary data in #IBS.

@AmCollegeGastro

Mast cell dysregulation may play a role in diarrhea and visceral hypersensitivity in some #IBS patients.

@AmCollegeGastro

Agents that target TRPV channels are being investigated for #IBS. (TPRV is also the mechanism for the efficacy of heat and capsaicin in cyclic vomiting syndrome!)

@AmCollegeGastro

Human milk oligosaccharides modulate the #microbiome, which may be beneficial for the dysbiosis in #IBS.

@AmCollegeGastro

#FMT has had conflicting data for #IBS.

@AmCollegeGastro

Multiple devices are being investigated for #IBS, such as this vibrating capsule!

@AmCollegeGastro

🔑 point from @AmCollegeGastro's #VirtualGrandRounds on management of #IBS.
My thoughts:
🟣NAME the diagnosis!
🟣lifestyle changes first
🟣treat most distressing symptom
🟣use evidence-based rx/OTC
🟣the fewer 💊💊💊, the better
🟣the future of IBS therapies is exciting! 🔥

@JCPetrov @loulev_md

From @RomeFoundation @RomeGastroPsych regarding neuromodulators.

And I like to use @UpToDate's table on antidepressant side effects to help guide therapy.