What I will cover today

Transcription

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2 What I will cover today Cost of IBS and the background to the CCG business case Allergy in FODMAP non-responders Frequently asked questions on the FODMAP diet Case study

3 The reality IBS patients incur 51% more total costs per year than a non- IBS control group 1,2 1. Maxion-Bergemann et al. (2006), Costs of irritable bowel syndrome in the UK and US. Pharmacoeconomics: 24 (1); Longstreth GF et al. (2003), Irritable bowel syndrome, health care use, and costs: A US managed care perspective. Am Journal of Gastroenterology: 98 (3);

4 The Statistics UK 45.6 million annually UK 1 in 12 GP consultations were for gastro symptoms 46% of which were diagnosed with IBS 2 USA 25% of gastroenterology outpatients diagnosed with IBS 1 (22% at YDH) References 1. Inadomi 2003; 2. Thompson 2000; 3. Max B 2006; 4. Longstreath 2003; 5. Lieberman DA 2005

5 Why does IBS involve secondary care? IBS is often a treated as a diagnosis by exclusion But GPs often refer into secondary care simply because there is no other option Spiegel BMR et al. (2010), Is irritable bowel syndrome a diagnosis of exclusion? A survey of primary care providers, gastroenterologists and IBS Experts. American Journal of Gastroenterology: 105(4);

6 The cycle of IBS frustration is costly Revolving door GP 3-10 times Medication 75% No treatment Blood tests 49% Coexisting conditions Secondary care referral 20% Poor quality of life Surgery 9% Investigation 90%

7 Making a Business Case

8 2011 Secondary care unnecessary costs 14.3% non red flag referrals into secondary care gastroenterology for IBS costing 161,000pa Figures thanks to Emma Greig, Consultant Gastroenterologist at Musgrove Park Hospital, Taunton

9 These figures do not take into account: Costs for pre appointment tests in previous 6 months GP visits 3-10 times for condition Revolving door patients 6.7% Medications/prescriptions

10 So what is the solution? NICE Guidance on IBS 2008 Early referral to a dietitian may lead to a reduction in future costs of care for people with IBS Irritable Bowel Syndrome: Costing report implementing NICE guidance. February 2008

11 Somerset Dietetic Led Gastroenterology Clinic July th December 2012 Data OUTCOMES/RESULTS n= % 3.7% % positive 127/162 % negative 29/162 % unclear 6/ % All referred for IBS. n=189 in total with 27 (14%) dropouts who did not complete the intervention therefore not included

12 The cost savings 161,198 for non red flag referrals into secondary care OR 58,853 cost of dietetic service with calprotectin tests Saving of 102,345 in just two district hospitals per annum

13 Non red flags Successful dietary intervention = Money saved

14 Thanks to the integrated approach of this multidisciplinary team. Flexible Healthcare Steering Group 9 th March 2012 Somerset Professional Executive Committee 7 th May 2012 Somerset Clinical Commissioning Group 26 th June 2012

15 The Somerset IBS Pathway IBS patients GP general community dietitian Intractable IBS patients (no red flags) specialist dietetic gastro service 65-74% improve are discharged Don t improve GP secondary care or CBT/hypnotherapy/medication

16 Purpose of pathway Commissioned as a service for primary care as an alternative to referral into secondary care Secondary care can refer into service via the GP

17 What we are commissioned for IBS Gastrointestinal Allergy ADULTS

18 What we see in reality? Gastrointestinal allergy Dairy +/- soya free Elimination diet Coeliac disease Gluten free diet IBS FODMAP diet Gluten Sensitivity Gluten free diet Dietetic Treatment

19 Similarity in symptoms Pain & Discomfort Bloating Wind Reflux Diarrhoea/Constipation Nausea

20 Percentage of type of diets used for patients referred with IBS who completed therapy n=83 12% 2% 1% 4% 4% 1% FODMAP Diet (63) Allergy diet (10) Gluten free diet (2) Other (3) FODMAP & Gluten (1) FODMAP & Allergy (3) FODMAP & Allergy & Gluten (1) 76%

21 Challenges In a primary care setting the dietitian must be able to differentiate between the IBS, gastro allergy & coeliac disease as symptoms can be extremely similar and often no 2 o care gastro involvement in IBS diagnosis

22 FODMAP NON-RESPONDERS

23 Is allergy a serious consideration in IBS?

24 Gastrointestinal allergy symptoms Pain & Discomfort Bloating Wind Reflux Diarrhoea/Constipation Nausea

25 Allergy or IBS? In many cases, gastrointestinal food allergy remains undiagnosed or is classified as irritable bowel syndrome. DRACMA World Allergy Report 2010: Milk Allergy Guidelines

26 1.2% - 3.2% allergy in adult population

27 Classic allergy/atopy

28 Allergy or IBS? Presence of an allergic background in IBS patients correlates with more severe disease and diarrhoea predominance Vivinus-Nebot 2012

29 GI allergy reactions are often Non-IgE Small and large intestine often exhibit delayed reactions starting several hours or days after ingestion and are non-ige and hence difficult to confirm on an objective basis S Holgate et al, Allergy, 2012, 4 th Edition, Elsevier

30 Nomenclature for food hypersensitivity Food Hypersensitivity Food Allergy Non-allergic food Hypersensitivity e.g. lactose, caffeine, additives IgE-mediated food allergy Non-IgE-med food allergy Report of the Nomenclature Review Committee of the World Allergy Organisation, October 2003

31 Allergy or IBS? In subsets of IBS patients, increased numbers of T-lymphocytes, mast cells, eosinophils cells have been found, but their exact role in food intolerance and symptom generation is unclear. Rajilic-Stojanovic M, Intestinal microbiota and diet in IBS: Causes, Consequences or Epiphenomena; Am J of Gastroenterology, 2015

32 Allergy or IBS? In subsets of individuals with functional GI diseases, GI allergy should be considered a differential diagnosis S Holgate et al, Allergy, 2012, 4 th Edition, p294, Elsevier

33 IBS Subgroups - a concept Carroccio A et al. Am j Gastroenterol :

34 Percentage of type of diets used for patients referred with IBS who completed therapy n=83 12% 2% 1% 4% 4% 1% FODMAP Diet (63) Allergy diet (10) Gluten free diet (2) Other (3) FODMAP & Gluten (1) FODMAP & Allergy (3) FODMAP & Allergy & Gluten (1) 76%

35 IBS patients using allergy diets Total numbers % Atopic history % Non-atopic % Patients % 31 37% 52 63% Allergy Diets 10 12% 7 8% 3 4% Positive Responses Diet Used for Positive Responders 7 8% 5 6% 2 2% Dairy Free x4 Elimination x1 Dairy/Soya Free x2

36 1.2% - 3.2% food allergy in adult population Potentially higher in the IBS population?

37 Frequently asked questions on the low FODMAP diet

38 Fructans e.g. Wheat, barley, rye Onion, garlic, brassicas FOS, inulin Galactans Beans & pulses Sorbitol e.g. sweetener Xylitol e.g. sugar free mints Manitol Stone fruit Fructans & Galactans (Oligosaccharide) Polyols Lactose (Disaccharides) Fructose (Monosaccharide) Mammalian milk Mammalian yogurt Processed cheese Reduced fat cheese Cottage cheese, quark, ricotta Honey Mango Sugar snap peas Fructose sweetener

39 This food is not listed in the book. Can I eat this food? No! This means that the food has not yet been tested so we can not determine if it is suitable This will also help prevent repeated questions from patients and make their decisions easier

40 Can I eat products made from spelt? Only 100% sourdough spelt bread as fermenting organisms will use the FODMAPs in the spelt flour Spelt bread/flour is otherwise not allowed No other spelt products are allowed

41 Can I cook with onions and garlic and remove them before eating the food? No The fructans in the garlic and onions will leach out into the food e.g. bolognaise, stew, casserole etc. Garlic oil is ok as the fructans do not leach into oil due to the viscosity of the oil Asafoetida powder (hing) is an ideal onion replacer Chives, green part of spring onions as an onion replacer

42 Do you remove all FODMAPs? Generally yes. Can choose to do separately but I find it easier to do all at the same time Lactose is the only exception if the patient is constipated

43 Do you use breath tests? They are not easily accessible in Somerset They are difficult to interpret They are very time consuming for the patient And only really useful for lactose and fructose which are easy to remove from the diet for a trial period

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45 Female age 52 post menopausal Severe bloating Abdominal discomfort Urgent diarrhoea BSS 6-7 x4-6/day 8 Wk Low FODMAP & strict gluten free = no difference Next approach: Atopic background hay-fever & eczema since childhood Strict dairy free diet 4 weeks Dramatic improvement in symptoms Lactofree dairy reintroduction =bad Dairy ladder = deterioration from start with trace amounts Long term strict dairy free diet Calcium supplements

46 DT Female, 72 yrs Sudden onset 2006 urgent loose stools BSS6-7, x3-4/day x2-3 am before breakfast, x1 afternoon Moderate bloating & wind No gastro red flags Colonoscopy 2008 NAD, bowel Ca screen 2011 NAD

47 Atopy Eczema as child until 20 s. Reoccurred in her 60 s & ongoing. Hay fever to pollen & rhinitis to dust

48 Coeliac disease No specific coeliac symptoms & negative bloods

49 Diet Diet high in FODMAP fruit and vegetables

50 Plan Low FODMAP diet, no lactose

51 1 st Review 8 weeks later Bloating improved and less urgency Stools still loose BSS6 x4 am STRICT LOW FODMAP, NO LACTOSE Wind unchanged

52 Conclusions so far NOT FODMAPs NOT lactose Could be spelt?

53 Dairy? Ovaltine with oat milk cheese spread Still eating g/f bread with milk powder ready sliced ham bertolli spread

54 Plan No suggestion of coeliac disease Atopic background with hayfever and childhood eczema Reoccurrence of eczema 10 years ago ongoing STRICT MAMMALIAN DAIRY FREE DIET

55 2 nd Review 4 weeks later No urgency Stools normal BSS4 x1-2 after breakfast Bloating and wind negligible

56 Patient comments I used to get up at 5.30am every morning and rush to the loo. Now I wake up at 8am and go to the loo with total control My energy is much better I feel a lot happier I feel more comfortable altogether and am so relieved that something has worked to help me

57 And don t forget Will need to use dairy ladder to see if has any level of tolerance Likely to need dairy free diet for life although challenge intermittently Will need calcium and vitamin D3 supplement (dairy free) Review in 6 months to check calcium intake and troubleshoot

58 A need for future collaborative research between gastroenterologists & allergists/immunologists

59 Always keep an open mind! MSc Allergy at Southampton: Food Allergy Module

60 Thank you for listening