NEL RISPETTO DELLE NUOVE DISPOSIZIONI IN MATERIA DI ECM, A SEGUITO DELL ATTUAZIONE DELL ACCORDO STATO-REGIONI DEL 5/11/09 E SUCCESSIVE
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1 NOME E NUMERO DEL PROVIDER: I&C SRL ECM N : TITOLO: XVII CONGRESSO NAZIONALE GISMAD SEDE: MILANO, HOTEL NHOW DATA: 09-10/03/2017 NEL RISPETTO DELLE NUOVE DISPOSIZIONI IN MATERIA DI ECM, A SEGUITO DELL ATTUAZIONE DELL ACCORDO STATO-REGIONI DEL 5/11/09 E SUCCESSIVE MODIFICHE, AL FINE DI GARANTIRE LA MASSIMA TRASPARENZA IN MATERIA DI CONFLITTO DI INTERESSI SI INFORMANO I DISCENTI CHE PRESSO IL DESK RELATORI SONO DISPONIBILI I DOCUMENTI ATTESTANTI LE EVENTUALI COLLABORAZIONI CHE I DOCENTI ABBIANO AVUTO NEL CORSO DELL ULTIMO BIENNIO CON AZIENDE FARMACEUTICHE E/O DIAGNOSTICHE DALLE QUALI SIA DERIVATA L EROGAZIONE DI COMPENSI O FINANZIAMENTI.
2 Stato dell arte sulla terapia dell IBS-C Maura Corsetti, MD PhD Nottingham Digestive Diseases Centre (NDDC) University of Nottingham UK
3 Why is important for gastroenterologists to study IBS? IBS account for up to 50% of consultations of gastroenterologists Corsetti M, Tack J et al. IBS Global Impact report
4 Rome IV Diagnostic Criteria for IBS Lacy BE, Gastroenterology 2016
5 Lacy BE, Gastroenterology 2016 Subtyping of IBS
6 The biopsychosocial model of IBS Predisposing factors Early trauma Abuse Family history of IBS Anxiety/Depression Triggering factors Infections Surgical operations Antibiotics Drugs Major loss Perpetuating factors Anxiety/Depression IBS Altered gut motility Visceral hypersensitivity Drossman DA, back in 1994
7 The psychological disturbances in IBS: cause or consequence?
8 The role of previous infections in IBS A systematic review has evaluated the results of studies reporting the percentage of infected individuals who develop PI-IBS and has found that between 4% and 36% of these subjects develop the functional disorder. PI-IBS has been described more frequently as consequence of bacterial infection than of a viral infection. PI-IBS can also occur in subjects with previous Clostridium Difficile infection and after a parasite infection. After 6 months from Clostridium infection, diagnosed by means of both culture and rapid immunoassay toxins detection, 25% of 205 patients without prior Rome III criteria IBS met this diagnosis. Rome Foundation Working Team on Post-Infectious IBS 2017
9 Gastroenterology 2004
10 Gut permeability: the key player in IBS Piche T, Neurogastroenterol Mot 2014
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12 Interaction between biopsychosocial factors and neurodegeneration Drossman DA, Neurogastroenterol Mot 2015
13 The role of visceral hypersensitivity and altered motility in IBS
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16 The colonic motility during Preprandial period Postprandial period Response to bisacodyl Healthy subjects n= 10 Painful constipation (treatment refractory) n= 15 + Symptoms Reduced number Painless constipation (treatment refractory) n= 10 No response n= 4 Corsetti M, FNM 2016
17 The effect of different foods on the small bowel water content as measured by MRI in health Hussein M, J Nutr 2015
18 The management of IBS
19 Which antispasmodic is effective in IBS-C? Ford AC, Am J Gastroenterol 2014; Camilleri M, Gut 2017
20 Laxatives
21 Am J Gastroenterol 2016
22 Antidepressants
23 The efficacy of antidepressants in IBS Ford AC, Am J Gastroenterol 2014
24 Which antidepressant is effective on pain in IBS-C? Ford AC, Am J Gastroenterol 2014
25 The use of antidepressants in IBS Dekel R, Expert Opin Investig Drugs 2013; Tornblom H, Neurogastroenterol Mot 2015
26 Linaclotide
27 Mechanism of action of linaclotide Corsetti M, United European Gastroenterol J 2013
28 Results of the phase III studies with linaclotide in IBS-C 26 week Corsetti M, United European Gastroenterol J 2013
29 Down-regulation of GC-C in patients with IBS-C DDW 2016
30 But how can we use these evidences?
31 1 Step: a good patient-doctor relationship! Explain IBS as hyper-reactive and hyper-sensitive gut and clarify it does not put the patient at risk of cancer Suggest simple and practical dietary and lifestyle advice of NICE guidelines
32 Then Linaclotide (290 µg 1 daily) Bloating: Low FODMAP diet Still abdominal pain: TCA Still abdominal pain but anxiety and depression: TCA and SSRI Still constipation: ballon expulsion test and if positive biofeedback if negative colonic transit time Rectal irrigation
33 Conclusions The state of the art treatment of IBS-C : - Remember the factors demonstrated to trigger the symptoms - Good patient-doctor relationship. - Some antispasmodics have been found to be effective in the short term but availability of the compounds across countries may limit their clinical application. - Peppermint oil has been found to be effective in the short-term. - Linaclotide has been recently approved by both FDA and EMA and demonstrated to be effective in the short- and in the long-term. - TCA and SSRI have been found to be effective but their clinical application is limited by adherence to treatment (doctors mistake!).
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35
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37 Lubiprostone
38 Mechanism of action of lubiprostone
39 Results of the phase III studies with lubiprostone in IBS-C Two phase-3 randomized trials of lubiprostone 8 mcg vs. placebo twice daily for 12 weeks in 1171 patients with a Rome II IBS-C Primary efficacy endpoint: % of overall responders (weekly assessments of symptom relief gathered from the responses to the question How would you rate your relief of IBS symptoms over the past week compared to how you felt before you entered the study? ) Drossman DA, Aliment Pharmacol Ther 2008
40 The effect of Lubiprostone on pain in IBS-C Drossman DA, Aliment Pharmacol Ther 2008
41 The role of previous surgical operations in IBS IBS receive twice as many appendectomies or hysterectomies, and two to three times as many cholecystectomies Longstreth GF, Yao JF. Irritable bowel syndrome and surgery: a multivariable analysis. Gastroenterology. 2004;126: Recent advances in insight into the underlying pathophysiology have identified intestinal inflammation triggered by handling of the intestine as the main mechanism for postoperative ileus. Boeckxstaens G, Gut 2009
42
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