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as an irritant to patients with IBS. Reduce alcohol and fizzy drinks. It may be helpful to limit the intake of high fibre food (such as wholemeal or high fibre flour and breads, cereals high in bran and whole grains such as brown rice). Reduce intake of processed or re-cooked foods. Limit fresh fruit to three portions a day. Patients with diarrhoea should avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks and in some diabetic and slimming products. Patients with wind and bloating may find it helpful to eat oats (such as an oat based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).

Patients’ intake of fibre should be reviewed and adjusted

whilst monitoring symptoms and should be discouraged from eating insoluble fibre such as bran. If an increase in dietary fibre is advised, it should be soluble fibre, such as ispaghula powder or foods high in soluble fibre (for example oats). If patients choose to take probiotics, they should be advised

to take these for at least four weeks and monitor their effect. Probiotics should always be taken according to the dose recommended by the manufacturers.2

The use of aloe vera in

treatment should be discouraged as there is little evidence to support its efficacy.2 If diet continues to be a major factor in the patient’s symptoms

and they are following general lifestyle /dietary advice, they should be referred to a dietician for advice and treatment, including single foods avoidance and exclusion diets. This advice should only be given by a dietician.6

PHARMACOLOGICAL THERAPY Decisions about pharmacological management should be based on the nature and severity of symptoms. This can be a choice of a single or combination of medication determined by the patient’s history and presenting symptoms. No single drug will alleviate the multiple symptoms often present in patients with IBS. Healthcare professionals should consider prescribing

antispasmodic agents for patients with IBS. These should be taken as required, but alongside dietary and lifestyle advice.2 Laxatives should be considered for the treatment of constipa-

tion in patients with IBS, but they should be discouraged from taking lactulose.2

Loperamide should be the first choice of

antimotility agent for diarrhoea in patients with IBS.2 Primary healthcare professionals should be able to advise

patients on how to adjust their doses of laxative or antimotility agent according to clinical need. The dose should be titrated according to stool consistency with the aim of achieving a soft, well formed stool (corresponding to Bristol Stool Form Scale type 4).2 Healthcare professionals should also consider tricyclic

antidepressants (TCAs) as second-line treatment for patients with IBS if laxatives, loperamide or antispasmodics have not helped. TCAs are primarily used for the treatment of depression, but are only recommended here for their analgesic effect. Patients should be started on at a low dose (5-10mg equivalent of amitripyline), which should be taken once at night and reviewed regularly. The dose may be increased, but does not usually exceed 30mg.2 Selective serotonin reuptake inhibitors (SSRIs) should only be

considered for patients with IBS if TCAs have been shown to be ineffective.2 Healthcare professionals will need to take into account possible

side effects when prescribing such medication and the patient should be followed up after four weeks and then at 6-12 monthly intervals.2

PSYCHOLOGICAL INTERVENTIONS Referral for psychological interventions (cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy) should be considered for patients with IBS who do not respond to pharmacological treatments after 12 months and w ho continue to develop symptoms (described as refractory IBS).2

COMPLEMENTARY AND ALTERNATIVE MEDICINE The use of acupuncture or reflexology should not be encouraged for the treatment of IBS.2

FOLLOWUP Follow up should be agreed between the healthcare professional and the patient and based on the response of the patient’s symptoms to interventions. This should form part of the annual patient review. The emergence of any ‘red flag’ symptoms during management and follow up should prompt further investigation and/or referral to secondary care. (NICE Guidance 2008).2

DISCUSSION Within your local practice, it is helpful if you have a Primary Care IBS pathway to ensure best practice. Questions you may ask in your practice are: What does our primary care IBS pathway look like? Where do our local protocols need updating to reflect all the recommendations in the NICE guideline? How can we manage the expectations of clinicians and patients about the use of tests to diagnose IBS? When should psychological therapies be considered? Are we as a practice offering ineffective treatments for IBS? For example, reflexology, acupuncture?

REFERENCES 1. Manning AP, Thompson WG, Heaton KW and Morris AF. Towards positive diagnosis of the IB, BMJ 1978;2; 2(6138):653-4.

2. National Institute for Health and Clinical Excellence. Guideline 61. Irritable Bowel Syndrome in Adults: Diagnosis and Management in Primary Care. London: NICE; 2008.

3. Lacy BE, Weiserk, Noddin L, Robertson DJ, Crowell MD, Parratt-Eng- strom C and Grau MV. IBS: Patients’ attitudes, concerns and level of knowledge. Alimentary Pharmacology and Therapeutics 2007;25(11):1329-41.

4. NHS Direct Data Statistics and Data Collections – the NHS Information Centre (Patient Survey 2006).

5. Office of National Statistics. Interim Life Tables, Expectation of Life, England and Wales. London: Office of National Statisitics; 2006.

6. National Institute for Health and Clinical Excellence. Public Health Intervention Guidance No. 2: four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community based programmes for walking and cycling. London: NICE; 2006.

7. Manning AP, Thompson WG, Heaton KW and Morris AF. Wheat Fibre and IBS. A controlled trial. Lancet 1977;2(8035):417-8.

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