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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Chronic Constipation And IBS:Helping Patients Move From Intestinal Distress To Intestinal Success


GOAL
To provide gastroenterologists and internists with up-to-date information on the treatment and management of patients with chronic constipation and irritable bowel syndrome.

TARGET AUDIENCE
This activity is designed for gastroenterologists and internists. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Discuss issues important to the appropriate diagnostic evaluation of the patient
    suspected of having chronic constipation or irritable bowel syndrome (IBS).
  • Compare the features of chronic constipation with those of IBS.
  • Explain the diagnostic workup for chronic constipation.
  • List treatment options and emerging therapies for chronic constipation.
  • Describe current and potential future treatments for irritable bowel syndrome vis-à-vis chronic constipation.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education
for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.The estimated time to complete this educational activity: 2 hours.

Release date: March 15, 2006.
Expiration date: March 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Sucampo Pharmaceuticals, Inc, and Takeda Pharmaceuticals North America, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Anthony N. Kalloo, MD
Chief, Division of Gastroenterology and Hepatology
The Johns Hopkins Hospital
Associate Professor of Medicine
Department of Gastroenterology
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Kalloo reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Lin Chang, MD
Associate Professor of Medicine
Co-Director, Center for Neurovisceral Sciences and Women's Health
David Geffen School of Medicine
University of California
Los Angeles, California
Dr Chang reports receiving grants/research support from and serving as a consultant for Novartis Pharmaceuticals Corporation.

Amy Foxx-Orenstein, DO, FACG, FACP
Associate Professor of Medicine
Mayo Clinic College of Medicine
Rochester, Minnesota
Dr Foxx-Orenstein receiving honoraria from Novartis Pharmaceuticals Corporation.

Lucinda A. Harris, MS, MD
Senior Associate Consultant
Division of Gastroenterology and Hepatology
Mayo Clinic
Scottsdale, Arizona
Dr Harris reports receiving research support from Novartis Pharmaceuticals Corporation.

Anthony J. Lembo, MD
Assistant Professor of Medicine
Harvard Medical School
Director, Motility Center
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Dr Lembo reports serving as a consultant for Novartis Pharmaceuticals Corporation, Salix Pharmaceuticals, Schwarz Pharma, and Takeda Pharmaceuticals North America, Inc.

Nicholas J. Talley, MD, PhD
Professor of Medicine
Mayo Clinic College of Medicine
Consultant, Division of Gastroenterology
Head, Motility Interest Group
Mayo Clinic
Rochester, Minnesota
Dr Talley reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Harris–various agents under development include alvimopam, asimadoline, mosapride, neurotrophin-3, and renzapride.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Chronic Constipation And Ibs: Helping Patients Move From Intestinal Distress To Intestinal Success
Anthony N. Kalloo, MD

Chronic constipation and irritable bowel syndrome (IBS) impose substantial physical, emotional, and economic burdens that should not be underestimated. IBS, for example, affects 10% to 15% of the US population, leading to $1.7 billion in annual healthcare costs. The prevalence exceeds that of other prominent morbid conditions, such as asthma1 and diabetes.2 Chronic constipation and IBS adversely affect several aspects of an individual's life, and many studies have shown that patients affected by these conditions have poorer quality of life compared to unaffected individuals.3-7

Irritable bowel syndrome and chronic constipation also have a substantial impact on the practice of medicine. IBS is second only to gastroesophageal reflux disease as a source of physician office visits related to gastrointestinal and liver disorders.8 Increasingly, as solutions arise for problems, such as inflammation and neoplasia, IBS will emerge as a disease of the future for the field of gastroenterology.

From a research perspective, medicine's ability to keep pace with the prevalence and impact of chronic constipation and IBS remains unclear. For fiscal year 2000, IBS ranked far behind other digestive conditions in terms of research funding commitments at the National Institutes of Health.8

Clinicians can offer a variety of therapeutic interventions to patients with chronic constipation or IBS. Conventional therapies for chronic constipation and IBS, such as fiber products and laxatives, have been the mainstay of treatment for many patients. However, their effectiveness varies greatly, and between 33% and 50% of patients express dissatisfaction with conventional therapies, primarily because of lack of efficacy.9,10

Investigation of potential alternatives to conventional therapies for constipation and IBS has produced several candidate agents. The first of these new therapies to become available is the serotonergic drug tegaserod, a partial 5-HT4 agonist. Other agents in various stages of clinical development include the chloride channel activator lubiprostone, the mixed serotonergic (5-HT4 agonist/5-HT3 antagonist) agents renzapride and mosapride, the opioid antagonists methylnaltrexone and alvimopan, and the neurotropic factor neurotrophin-3.

A panel of gastroenterology specialists recently met to discuss current and future directions in the diagnosis, evaluation, and management of chronic constipation and IBS. This issue of Johns Hopkins Advanced Studies in Medicine summarizes the proceedings of that meeting.

Nicholas J. Talley, MD, PhD, from the Mayo Clinic in Rochester, Minn, discusses the epidemiology, presentation, and diagnosis of patients with chronic constipation and IBS. The summary highlights differences in patient and physician criteria for defining constipation, reviews key signs and symptoms, and offers a concise description of the basic approach to diagnosis and patient evaluation.

Lin Chang, MD, of the University of California, Los Angeles, reviews the issues related to pathophysiology and mechanisms of action of current therapies. The presentation includes emerging information on the brain-gut connection to constipation and IBS and the potential pathophysiologic contributions of immune activation.

Lucinda A. Harris, MS, MD, of the Mayo Clinic in Scottsdale, Ariz, provides an overview of current and emerging therapies for chronic constipation and IBS. Several new agents in development could substantially expand the number of options that clinicians can offer to their patients.

Finally, Anthony J. Lembo, MD,  of Harvard Medical School in Boston, Mass, rounds out the information with a discussion of practical issues in the management of chronic constipation and IBS. The summary revolves around case presentations that reflect the patients that present in clinical practice.

The information in this issue of Johns Hopkins Advanced Studies in Medicine offers a concise summation of current issues in the diagnosis, evaluation, and treatment of chronic constipation and IBS. Clinicians in a variety of practice settings will find the material readily applicable to their own patient populations.

The content in this monograph was developed with
the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.


REFERENCES

1. Centers for Disease Control and Prevention. Asthma prevalence and control characteristics by race/ethnicity-United States, 2002. MMWR Morb Mortal Wkly Rep. 2004;53:145-148.
2. Centers for Disease Control and Prevention. Prevalence of diabetes and impaired fasting glucose in adults-United States, 1999-2000. MMWR Morb Mortal Wkly Rep. 2003;52:833-837.
3. Talley NJ, OÕKeefe EA, Zinsmeister AR, Melton LJ 3d. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology. 1992;102:895-901.
4. Glia A, Lindberg G. Quality of life in patients with different types of functional constipation. Scand J Gastroenterol. 1997;32:1083-1089.
5. Frank L, Kleinman L, Rentz A, et al. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.
6. Li FX, Patten SB, Hilsden RJ, Sutherland LR. Irritable bowel syndrome and health-related quality of life: a population-based study in Calgary, Alberta. Can J Gastroenterol. 2003;17:259-263.
7. OÕKeefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. Bowel disorders impair functional status and quality of life in the elderly: a population-based study. J Gerontol A Biol Sci Med Sci. 1995;50:M184-M189.
8. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1511.
9. Irvine EJ, Ferrazzi S, Pare P, et al. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am J Gastroenterol. 2002;97:1986-1993.
10. Ferrazzi S, Thompson GW, Irvine EJ, et al. Diagnosis of constipation in family practice. Can J Gastroenterol. 2002;16:159-164.


*Chief, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Associate Professor of Medicine, Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Anthony N. Kalloo, MD, Chief, Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Associate Professor of Medicine, Department of Gastroenterology, Johns Hopkins University School of Medicine, 1830 Building - Room 419, 600 North Wolfe Street, Baltimore, MD 21287.
E-mail:
akalloo@jhmi.edu.





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