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Addendum to NICE guideline CG61, Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care. London: National Institute for Health and Care Excellence (NICE); 2015 Feb. (NICE guideline, No. CG61.1.)
Addendum to NICE guideline CG61, Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care.
Show details1.1. Update information
The NICE guideline on irritable bowel syndrome (IBS) in adults (NICE guideline CG61) was published in 2008. It was reviewed in 2011 and 2013 as part of NICE’s routine surveillance programme to decide whether it required updating. These surveillance reports identified new evidence relating to the following areas of the guidance:
- The role of antidepressants in IBS management
- The role of relaxation therapy in IBS management.
A further two areas were identified where there was evidence suggesting that newer treatments for IBS that were not in CG61 should be included in this update:
- The use of linaclotide and lubiprostone in constipation predominant IBS (IBS-C) management
- The use of the low FODMAP (fermentable oligosacchardies, disaccahrides, monosaccharides and polyols) diet in IBS management.
Consultation with IBS topic-specific members of the update Committee during the development of the review protocol further identified that the use of some psychological interventions (computerised CBT and mindfulness therapy) in the management of IBS should also be updated. Therefore a review question in this area (5a and 5b) was added to the update review protocol (this encompasses the relaxation therapy question).
New recommendations relating to the clinical management (dietary and lifestyle advice, and pharmacological therapy) of IBS have been made in this addendum. These are marked as:
- [new 2015] if the evidence has been reviewed and the recommendation has been added or updated
- [2015] if the evidence has been reviewed but no change has been made to the recommendation action.
This update replaces recommendations 1.2.1.8 and 1.2.2.5–1.2.2.7 in the original irritable bowel syndrome in adults guideline.
1.2. Strength of recommendations
Some recommendations can be made with more certainty than others. The Committee makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Committee is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).
For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also ‘Patient-centred care’).
1.2.1. Interventions that must (or must not) be used
We usually use ‘must’ or ‘must not’ only if there is a legal duty to apply the recommendation. Occasionally we use ‘must’ (or ‘must not’) if the consequences of not following the recommendation could be extremely serious or potentially life threatening.
1.2.2. Interventions that should (or should not) be used – a ‘strong’ recommendation
We use ‘offer’ (and similar words such as ‘refer’ or ‘advise’) when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, ‘Do not offer…’) when we are confident that an intervention will not be of benefit for most patients.
1.2.3. Interventions that could be used
We use ‘consider’ when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.
1.3. Recommendations
Antidepressants
- 1.
Consider tricyclic antidepressants (TCAs) as second-line treatment for people with IBS if laxatives, loperamide or antispasmodics have not helped. Start treatment at a low dose (5–10 mg equivalent of amitriptyline), taken once at night, and review regularly. Increase the dose if needed, but not usually beyond 30 mg. [2015] 1
- 2.
Consider selective serotonin reuptake inhibitors (SSRIs) for people with IBS only if TCAs are ineffective. [2015] 1
- 3.
Take into account the possible side effects when offering TCAs or SSRIs to people with IBS. Follow up people taking either of these drugs for the first time at low doses for the treatment of pain or discomfort in IBS after 4 weeks and then every 6–12 months. [2015] 1
Low FODMAP diet
- 4.
If a person’s IBS symptoms persist while following general lifestyle and dietary advice, offer advice on further dietary management. Such advice should:
- include single food avoidance and exclusion diets (for example, a low FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diet)
- only be given by a healthcare professional with expertise in dietary management. [new 2015]
Linaclotide
- 5.
Consider linaclotide for people with IBS only if:
- optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
- they have had constipation for at least 12 months.
Follow up people taking linaclotide after 3 months. [new 2015]
Lubiprostone
- 6.
No recommendation
Psychological interventions (relaxation, computerised CBT and mindfulness therapy)
- 7.
No recommendation
- 1
At the time of publication (February 2015), TCAs and SSRIs did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.
1.4. Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Healthcare professionals should follow the Department of Health’s advice on consent. If someone does not have the capacity to make decisions, healthcare professional should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in Patient experience in adult NHS services.
1.5. Methods
Please see the interim process and methods guide for updates pilot programme 2013 and the guidelines manual 2012.
- Summary section - Addendum to NICE guideline CG61, Irritable bowel syndrome in a...Summary section - Addendum to NICE guideline CG61, Irritable bowel syndrome in adults
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