Treatment algorithm created for chronic idiopathic constipation and constipation-predominant IBS based on national survey

By Al Saint Jacques, MDLinx
Published March 6, 2017

Key Takeaways

A treatment algorithm for chronic idiopathic constipation (CIC) and constipation-predominant irritable bowel syndrome (IBS-C) was created based on a survey of practicing physicians in Canada to provide clinical guidance in the management of these conditions, according to a study published in the February 8 issue of the Canadian Journal of Gastroenterology and Hepatology.

Study authors pointed out that CIC and IBS-C are common gastrointestinal disorders in North America, with CIC affecting 15% to 25% of the general population and IBS-C affecting 11.8%. Canada is one of the countries that has a high rate of IBS in the world, with a prevalence estimated to be 1 in 7 in the population, with an incidence of 120,000 new cases per year. IBS-C is found to be more common in females and younger adults of less than 50 years of age, whereas CIC more commonly affects females and older adults. CIC and IBS-C impair patient’s quality of life (QoL), similar to those who suffer from asthma and rheumatoid arthritis, and they negatively impact the socioeconomics of the society.

Although the Rome III diagnostic criteria define CIC and IBS-C as separate entities, with IBS-C being distinguished by the presence of abdominal pain and discomfort, these criteria cannot reliably distinguish between CIC and IBS-C, explained study authors led by Yvonne Tse of the University of Toronto, Toronto, Ontario, Canada. Many patients have features of both disorders and their diagnosis may change over time. In 2014, America College of Gastroenterology (ACG) published a systematic review on the efficacy of available therapy in IBS and CIC. Earlier in 2013, the American Gastroenterological Association (AGA) published a medical position statement on constipation, followed by an AGA guideline on pharmacological management of IBS in 2014. However, none of these guidelines were found to provide direction in terms of the priority of use for the therapeutic agents to be used to optimize management in patients suffering from CIC and IBS-C.

In this study, researchers used a national survey to evaluate Canadian specialists’ practice patterns in the utilization and satisfaction of various therapeutic agents for their CIC and IBS-C patients. The survey also asked if the respondents found the new ACG guidelines useful as a guide for which agents to use in their clinical practice. The questionnaire was sent to 350 Canadian physicians and data were collected over a 4-month period in early 2015 to evaluate respondents’ area of practice and their constipation management patterns in patients with CIC and IBS-C.

When results were analyzed, a treatment algorithm was developed for the management of CIC and IBS-C. This treatment algorithm was compared with the recently published literature (ACG and AGA guidelines), while also considering the limitations of these American guidelines in the Canadian practice.

A total of 55 of 350 (16%) physicians completed the questionnaires. Almost all (96%) respondents reported that they followed a standard, graduated, or stepwise approach for managing constipation; however, only 24% of respondents reported that referring physicians used a graduated or stepwise approach in managing patients with constipation, according to researchers. A majority of respondents reported that patients (59%) and referring physicians (62%) were reluctant to move from over-the-counter (OTC) therapies to prescription medications.

Researchers found that among the six therapeutic options to use to manage constipation, respondents selected osmotic laxatives and fiber supplements/bulking agents as the first-line (ranked as answer 1 or 2) treatment of both CIC and IBS-C. Stool softeners were shown to be the least satisfying treatment option for patients with CIC when analyzing the responses from those who rated each treatment option as answer 1. When ratings of 1 and 2 were grouped for analysis, stimulant laxatives were also found to be an unsatisfying treatment option for CIC. On the other hand, the guanylyl cyclase C (GCC) agonist, osmotic laxatives, 5-HT4 agonists, and fiber supplements/bulking agents were considered to be satisfying treatments for CIC.

For patients with IBS-C, respondents identified both stool softeners and stimulant laxatives as significantly unsatisfying treatment options. Similar to the management of CIC, the GCC agonist, osmotic laxatives, 5-HT4 agonists, and fiber supplements/bulking agents were considered to be satisfying treatments for IBS-C, with the GCC agonist being the most satisfying treatment option.

In other survey results, researchers reported that abdominal pain and bloating were ranked as being the most burdensome symptoms that affect QoL in patients experiencing CIC and IBS-C (28% and 32%, respectively). “Our survey indicated that the respondents reported that their patients least likely complained of abdominal pain and bloating while using the GCC agonist, suggesting that this agent may be the most effective to alleviate patients with constipation and abdominal pain and bloating and least likely to cause these symptoms as side effects,” study authors explained.

In addition, study authors acknowledged that although the majority of respondents (69%) indicated that they were aware of the recent ACG guidelines for managing CIC and IBS-C, only half of the respondents (39%, somewhat helpful, 11%, very helpful) found the guidelines to be helpful in prioritizing the use of available treatment options. Furthermore, most of them (69%) expressed great interest in having a treatment algorithm that would be applicable to Canadian practice.

Researchers concluded that this survey suggests that management strategies for CIC and IBS-C among physicians are heterogeneous, which can lead to dissatisfaction in treatment response from both patients and physicians. They suggested that a management algorithm for chronic constipation specifically developed to apply in Canadian practice will help in optimizing treatment outcomes for patients suffering from these functional GI disorders.

In addition to Yvonne Tse, other study authors included David Armstrong, Christopher N Andrews, Alain Bitton, Brian Bressler, John Marshall, and Louis WC Liu.

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