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Saturday, October 28, 2017

Prescription Medications for Constipation

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Constipation is an incredibly common problem-by some estimates affecting 27% of the population. One review found that 63 million people in North America are affected. Definitions of constipation vary, but most include the criteria of less than 3 bowel movements per week.

Patients who see me in the office often- in addition to decreased bowel movement frequency-complain of hard stools, straining, of sensation of incomplete bowel movements.

While patients often self-medicate for constipation, it is wise to seek professional medical advice, since constipation can be the result of an underlying serious medical problem, and can even be a sign of colon cancer. When I see a patient with constipation, I generally review their dietary habits, review their medication list looking for medications that may be contributing to their constipation,  and perform a thorough physical exam. Depending on the situation, I may order blood tests looking for such issues as an underachieve thyroid-which can lead to constipation. I may also order x-ray studies, check for blood in the stool, or suggest a colonoscopy.

Once I have determined that the patient has "idiopathic" constipation-which basically means that there is no obvious underlying correctable cause( such as an underachieve thyroid, constipating medications, etc) I usually suggest some simple interventions-such as encouraging adequate dietary fiber, adequate fluid intake, and adequate physical activity-simple, natural measures that often work.

My next step is usually to consider Miralax(polyethylene glycol). This is a powder laxative, that is mixed with water. While it is not a "natural" substance, I believe it to be safe, and is generally effective. Some patients are able to take it on occasion "as needed", while others find that they need to use it on a regular basis.

If lifestyle changes and miralax are not getting the job done, I sometimes recommend a prescription laxative. The three prescription laxatives that I generally consider for my patients are: 1) Amitiza (lubiprostone) 2) Linzess(linaclotide) 3) Trulance (plecanitide)

Amitiza was approved by the Food and Drug Administration(FDA) in 2007. It is current FDA approved for the treatment of Chronic Idiopathic Constipation, Irritable Bowel Syndrome with Constipation, and Constipation Caused by Opioids. Nausea is the most common side effect of the medication-though there are other potential side effects that you should discuss with your doctor if this is prescribed to you. It is a twice per day medication. Nausea can be reduced by taking it with food and water.

Linzess was FDA approved in 2012. It is FDA approved for Chronic Idiopathic Constipation, and Irritable Bowel Syndrome with Constipation. Linzess is taken once daily. The most common side effect is diarrhea, though, again, there are other potential side effects that should be reviewed with the prescribing physician.

Finally, the most recent addition is Trulance, which was FDA approved in January of 2017. It is also a once daily product. It is FDA approved for Chronic Idiopathic Constipation. Like Linzess, the most common side effect is diarrhea.

I will share some thoughts on use of these medications from my experience with my patients. This is not intended as a comprehensive review of these products, nor should it be interpreted as specific advice. Every patient's situation is unique, and-as stated above-you should seek professional medical advice for your particular situation.

I feel that these medications are generally safe, generally well tolerated, and have a convenient dosing schedule. They don't work for everybody. On the other hand, sometimes they work too well! By that I mean that they can cause diarrhea. Sometimes the diarrhea can be severe, and even cause dangerous dehydration, requiring discontinuation of the medication. I usually caution patients to watch out for diarrhea, and even plan to stay close to their home for several days after starting the medication. Often times if diarrhea occurs initially, it may resolve after a few days. I encourage patients to "hang in there", drink plenty of fluids to stay hydrated, and if the initial diarrhea resolves, then they may be able to continue the medication. But, of course, if the diarrhea is severe or persistent the medication may need to be discontinued.

In addition to the above, it has been my experience that sometimes patients have an excellent response, but at some point lose the response and the medication stops working. My approach to those patients is usually to try another medication in place of the one that stopped working. However, at some point, I suggest re-starting the original medication, since often after a "drug holiday" the original medication may work once again. Other physicians may approach these medications differently.

While lifestyle and diet modifications are often adequate to treat constipation, the prescription products mentioned above have added significantly to our ability to help patients with constipation.

Friday, December 4, 2015

Peppermint Oil for IBS

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Irritable Bowel Syndrome (IBS) is the most common gastrointestinal condition in America, affecting 15-20% of the adult population. The most common symptoms of IBS are abdominal pain, and changes in the bowel pattern,either constipation, diarrhea, or alternating constipation and diarrhea. Amazingly, our understanding of IBS is still very limited, and treatments have been less than satisfactory. 

While there have been several prescription drugs developed for IBS over the last several decades, these advances have been countered by the fact that several of the new medications that were released had to be withdrawn from the market due to safety concerns. This has left many patients searching for safer, more natural solutions for their IBS symptoms. Enter peppermint oil. Recognized for years as a remedy for digestive problems, peppermint oil seems to have found new life as a natural treatment for IBS.

There have been numerous scientific studies supporting the effectiveness of peppermint oil for pain and bowel dysfunction resulting from IBS. But what seems to have caused the renaissance in peppermint oil enthusiasm is the aggressive marketing of a new peppermint oil product-IBgard-by a company called IM Health Science. IBgard’s sleek packaging and marketing campaign seem to be working. But the product is not cheap. The directions say to take 1-2 capsules three times daily. A box of 48 capsules is $29.99. If you take 6 capsules a day, that box of 48 will last only 8 days.  While this seems a bit pricey, the good news is that there are other companies making similar products at a lower price point. For example, Pepogest by Nature’s Way costs $11.49 on the Walgreen’s website for a container of 60 capsules, which comes to a 20 days supply (if taken three times per day as directed).

Although it is a natural, and basically safe product, peppermint oil does have some safety issues. For example, due to the potential for decreased milk production, it should probably be used sparingly toward the end of pregnancy, and during breastfeeding. It is generally not advisable for children under seven. There is concern about causing low blood sugar in diabetics, and there has been a link to gallbladder inflammation. Finally, those with gastroesophageal reflux must be aware of the fact that peppermint oil can lower the pressure in the lower esophageal sphincter and cause aggravation of the acid reflux.

Despite these cautions, I am enthusiastic about the renewed interest in peppermint oil as an option for my IBS patients. I am hopeful that as our understanding about the underlying nature of IBS evolves, we will have more to offer our patients.

Saturday, January 3, 2015

Fecal DNA Testing: Passing Fancy or the Demise of Colonoscopy?

Fecal DNA Testing: Passing Fancy or the Demise of Colonoscopy?

For many years, there have been attempts to find easier and less expensive alternatives to colonoscopy as a means to screen for colorectal cancer. The stakes are quite high. There were an estimated 136,830 new cases of colorectal cancer in the United States in 2014, and 50,310 deaths from colorectal cancer in the same period.  The estimated 5 year survival is approximately 64.7%

As alarming as these statistics are, there has been a clear trend toward improvement since the advent of routine screening colonoscopy. Medicare began to pay for screening colonoscopies in “high risk” individuals in the 1980's and 1990’s and began coverage for average risk people in 2001.  Most analysts attribute the steady decrease in the rate of new cases and deaths from colorectal cancer to the more widespread acceptance of screening colonoscopy. In fact, it is estimated that if everyone age 50 (the recommended started point for most patients)and up were screened via colonoscopy, it would result in an 80% prevention of colon cancer, and a 60% reduction in deaths from colon cancer.

Despite these compelling facts, it is estimated that at least one in three Americans of the appropriate age(50-75)has not been tested for colorectal cancer, and therefore is needlessly at risk for this preventable problem. The reasons for this are multiple, and include inadequate public awareness, cost, inadequate access to medical resources, and fear of what some perceive to be an invasive medical procedure.

Current guidelines indicate that colonoscopy is the superior method for screening, since it effective for both early detection of colorectal cancer, as well as prevention(by detecting and removing pre-cancerous polyps). Average risk individuals are advised to have colonoscopy starting at age 50(45 for African Americans), then every 10 years if normal. For individuals who decline colonoscopy, yearly FIT(fecal immunochemical testing) is advised as an alternative.  This is a test that can detect tiny amounts of blood in the stool, which may indicate the presence of a colon tumor. While FIT is less invasive than colonoscopy(it involves submitting a scraping from a stool specimen), it is problematic in the sense that it is less likely to pick up cancers than colonoscopy, only detecting 79% of cancers.

To try and combat this lower rate of detection, researchers have combined the FIT test with a fecal DNA test, which can detect abnormal DNA in the stool, which has been shed by tumor cells in the colon.  The results were encouraging. The DNA test discovered 60 of the 65 cancers for an accuracy rate of approximately 92%.  The cost, according to Cologuard, by Exact Sciences Laboratories, is $599.

The role for fecal DNA testing remains to be seen. Like FIT, it is less likely to find colon cancers than colonoscopy. If it is utilized routinely to screen individuals, other issues such as the high false positive rate(meaning an abnormal stool test, when there is actually no tumor present), as well as the frequency with which such tests should be done, must be resolved.
Where does fecal DNA and FIT “fit” into my practice?(sorry-couldn’t help it!). I continue to recommend colonoscopy as the screening test of choice. It is hard for me to offer other tests as “first line”. Colonoscopy is the “gold standard” for accuracy, is well documented to save lives, and has withstood the test of time as en effective tool for detecting, and preventing colon cancer.

I offer fecal DNA testing and/or FIT as an alternate strategy for patients who refuse to undergo colonoscopy, or who-because of other serious medical conditions-may be poor candidates for colonoscopy. While cost and accuracy with fecal DNA testing remain a problem, it definitely represents an advance by offering another tool in the fight against colon cancer.

Wednesday, July 23, 2014

Probiotics and Irritable Bowel Syndrome

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Two topics that are very hot in the world of Gastroenterology are: 1) Probiotics 2) Irritable Bowel Syndrome. How are they related? Irritable Bowel Syndrome, while it is the most common Gastrointestinal problem in America, is still not well understood. It is what we call a functional disorder of the bowel, meaning that you cannot see it on x-ray, endoscopy, or biopsy. Rather than a structural issue, it is more a disorder of how the bowel functions. My own view is that Irritable Bowel Syndrome (IBS) is probably multiple different disorders that we lump together under one name, essentially because we don't know any better at this point.

If you accept my position that IBS is probably multiple different disorders rather than a single entity, then   it follows that there may be multiple different mechanisms for the various disorders. One such mechanism is probably an imbalance in the normal bacterial flora of the gut. We all have billions of bacteria in the gut-principally in the colon. These bacteria live in a certain harmony and balance. One likely mechanism for bowel dysfunction is imbalance in the normal flora. Possible causes of such imbalance could include intestinal infections, antibiotics, and chemotherapy agents.

The idea of a probiotic is to add "good" bacteria to the gut, and rebalance the flora. I often recommend probiotics to patients with IBS. Since IBS is not always due to bacterial imbalance, it doesn't help everyone. It is not possible, in my opinion, to know up front who will benefit and who will not. However, probiotics are safe, easily accessible, and fairly inexpensive(although if you want to drop some serious cash on a probiotic, there are no shortage of expensive ones!!).

As far as which probiotic is best, there is really not a tremendous amount of data to help us. My own practice is to recommend a probiotic that contains lactobacillus acidophilus(most probiotics do contain this strain of bacteria). If someone is already taking a probiotic and not getting the results they hoped for, I often recommend switching to Florastor. Florastor, rather containing bacteria, contains a yeast called saccharomyces boulardii. I am not implying that Florastor is better than probiotics that contain bacteria, it is simply different, so if bacteria-containing probiotics don't work, try yeast-containing probiotics.

Monday, January 20, 2014

Colonoscopy Prep Can Be Fun!!

As we have discussed in previous posts, the preparation for a colonoscopy is one of the most vital, yet annoying, parts of the entire process.

Sometimes, however, we have to take these things with a little sense of humor!  I thought I would share this clever, and funny video with you. I hope you enjoy it, and use it to spread the word about colon cancer screening.

Kudos to Dr. David Rosenfeld for using his imagination!!

Hilarious Colonoscopy Prep Video

Saturday, January 4, 2014

Irritable Bowel Syndrome

Irritable Bowel Syndrome

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

Tackling the topic of Irritable Bowel Syndrome(IBS) is ambitious, for many reasons. For one, it is the most common gastrointestinal disorder in America, affecting up to 10-15% of the population. Another reason it is a difficult topic to manage is the fact that IBS means different things to different people, including health care professionals. While there are well defined diagnostic criteria for IBS(Rome Criteria), not all healthcare providers utilize these criteria. To make matters even more dicey, IBS is what can be considered a "functional" disorder, meaning that it is a disorder of how the bowel functions rather that a structural abnormality.  What this means is that you can't see it with a scope, you can't see it with an x-ray, you can't detect it with a blood test(tho there is some excitement about a new blood test that might be promising), and you can't prove it via a biopsy. 

The elusive nature of the diagnosis sometimes creates the illusion that this is an imaginary illness. It is not. Patients with IBS sometimes get frustrated with healthcare providers, feeling that they are being treated as if the disorder is psychosomatic. Indeed, sometimes physicians do treat patients as if IBS is not a legitimate medical illness. I like to use the following analogy with patients: I explain IBS can be likened to migraine headaches, in the sense that you can't really demonstrate a migraine on an x-ray, blood test, or biopsy. Yet, we know that migraines are a legitimate disorder, and just because we can't see or touch them doesn't minimize the grief they cause. The same goes for IBS. 

Another feature of IBS that presents a challenge is the fact that, despite its prevalence, it is poorly understood. This lack of  understanding about some of the most basic features of IBS, such as what causes it, leads to a number of unfortunate consequences. For one, when the medical establishment doesn't understand a disease entity, and has challenges treating it, there is a tendency to pawn it off as a psychosomatic disorder, or to try to avoid seeing such patients, whom they may perceive as a nuisance. A second unfortunate consequence is that IBS patients become prey to charlatans who hawk unproven, useless, and costly remedies, that waste their time and money. It is understandable, however, that patients look outside the mainstream when they feel that their needs are not being met. 

In reality, IBS is probably not a single illness, but rather a multitude of different disorders that we lump together under a single banner, because we currently don't know any better. The different individual disorders probably each have a separate underlying cause, and thus should probably be treated differently. The state of the art, however, is such that currently it is difficult to really distinguish between these "variations" of IBS. I truly believe that one day we will be able to pinpoint the type of functional gastrointestinal disorder a patient has(versus lumping them together under the IBS umbrella), and focus our treatment in a much more effective manner. There is definitely progress being made.

This series will outline some of the variants of IBS that are currently recognized, as well as the current state of the art as far as treatment goes. Along the way I will interject my observations and personal experiences, having cared for IBS patients for over 25 years. I hope you find it helpful and meaningful for yourself or someone you care about.

Monday, September 30, 2013

Affordable Care Act?

September 30, 2013 will probably not go down as a hugely memorable day in history. Yet, it represents   a pretty momentous confluence of events. On the one hand, there is the threat of an impending government shutdown based on partisan squabbling predicated on the defunding of the Affordable Care Act, or Obamacare, as it is widely known. We are on the brink of ......well, brinksmanship.

On the other hand, we are also on the brink of the inauguration of Health Exchanges-one of the cornerstones of the Affordable Care Act. The Exchanges represent a pretty grandiose social experiment. The goals of the Exchanges seem pretty laudable: reduce insurance premiums, allow those with preexisting conditions to get coverage, allow small businesses and families to have the same kind of leverage with insurers that large employers have.

There are many unknowns as to how, in fact, this will play out. And people should probably use a great deal of caution before chucking whatever plan they currently have. One of the gigantic question marks about the exchanges is a very practical one-how much will the insurance plans offered cost the consumer, and will that actually represent a savings over their current plan?

The fact that patients with pre-existing conditions must be allowed to purchase insurance on the exchange leads me to believe that insurance premiums are bound to go up rather than down. Obviously, if an insurer has a pool of insured people that are highly likely to use a large amount of medical services, they have to charge more to mitigate this risk.  In addition,somehow insurers must pay for the  laundry list of services that must be included for plans offered on the exchanges, such as prescription drug coverage and wellness services, somehow that must be paid for.

It is estimated that only a small portion  of the population will be using the exchanges. If you have existing insurance through your employer, you are only eligible for the exchange if your portion of the premium is over 9.5% of your income. Furthermore, Medicare recipients are not eligible. Further reducing the eligible pool of participants in the Exchanges, is that some states have elected to opt out of creating Exchanges. Those states who do not have an exchange will have a federally run exchange starting in 2014.  The exchanges will probably be applicable to only about 20 million people-more or less.

If you do not currently have health insurance, and you are eligible for the Exchange and you fail to purchase insurance, you will be fined $95. This fine will gradually escalate to $695 over the next few years.

So how will insurers try to keep down the cost of insurance plans offered on the exchanges? Physicians are very fearful that their reimbursement for work done under the auspices of insurance plans offered on the Exchange plans will go way down. One physician organization indicated that reimbursement was a low as 70% below more conventional insurance plans.