MUR case study: uncontrolled irritable bowel syndrome

Issue

Mebeverine during pregnancy

Recommendation

According to the BNF, mebeverine is not known to be harmful during pregnancy. However, the manufacturer advises avoiding its use. While peppermint oil capsules are also not known to be harmful during pregnancy, the BNF does not include a manufacturer's warning. Therefore peppermint oil capsules should be the preferred anti-spasmodic agent.

For action by

GP: Switch to peppermint oil capsules as BNF indicates preferable during pregnancy.

Patient: Explain that the GP may prescribe an alternative anti-spasmodic which is proven not to be harmful during pregnancy, but will still help to control stomach cramps.

Issue

Poor lactulose use, as patient doesn't find it convenient to carry about

Recommendation

Lactulose is an osmotic laxative and is safe to use regularly, and during pregnancy. If the patient would prefer an alternative laxative, you could suggest a bulk-forming laxative in sachet form that can be carried about easily. As it is not absorbed into the body, it is considered safe in pregnancy.

For action by

Patient: If continuing to use lactulose, it may be worthwhile using a smaller container to carry it out and about. If the GP does choose to prescribe a different laxative, the patient should be made aware that she can carry sachets discreetly.

Pharmacist: Explain to the patient that lactulose does not work immediately and that she doesn't need to take it when symptoms become apparent – therefore she doesn't necessarily need to carry it about.

GP: It may be appropriate to change the directions on the lactulose prescription to take daily, rather than simply "when required", as the patient is not using frequently and consequently is having bouts of constipation. The patient complains that lactulose is not easy to take with her when she is not in the house, so it may be appropriate to provide laxative that comes in sachet format, such as a bulk-forming laxative such as Fybogel.

Issue

Patient complains of occasionally being bloated

Recommendation

Patient requires dietary advice to help avoid the symptoms of bloating.

For action by

Patient: Keep a food diary to try to ascertain which foods are causing bloating. Oats and linseeds (up to one tablespoon per day) can easily be incorporated into the diet and are recommended to reduce wind and bloating.

Issue

Patient thinks CBT may help her anxiety and consequently her IBS

Recommendation

Advise the patient of the importance of self-help mechanisms for effective management of IBS. Recommend further reading to aid the patient. Advise the patient that she may not be eligible for CBT, but she should still speak to her GP.

For action by

GP: Nice recommends that referral for psychological interventions – such as CBT – should be considered in patients who do not respond to pharmacological treatment after 12 months and who develop a continuing symptom profile. The GP should assess the patient's anxiety and determine if treatment is required.

Patient: Speak to the GP about your anxiety.

Issue

Healthy living advice

Recommendation

To ensure the symptoms of IBS are minimised, and health of the unborn baby is optimised.

For action by

The pharmacist and the patient should discuss the following points:

• Diet and lifestyle advice is particularly important for IBS sufferers and during pregnancy.
• Start folic acid 400 microgram supplements straight away – if the patient hasn’t already – to prevent neural tube defects in her unborn baby.
• Eat regular meals and allow time to eat.
• Miss Blake already suffers from constipation and this is very common during pregnancy. Ensure the patient uses a laxative regularly. In addition, you should advise IBS sufferers to review their fibre intake as this can often improve symptoms. Insoluble fibre should be avoided where possible and replaced with soluble forms such as oats, fruit and vegetables.
• Alcohol and fizzy drinks should be avoided both during pregnancy and for IBS sufferers. Drink at least eight glasses of fluid per day – preferably water and non-caffeinated drinks. You should also remind Miss Blake to restrict tea and coffee.
• Moderate exercise should be maintained during pregnancy and will help to reduce stress, thus improving any anxiety-related IBS symptoms. Examples of suitable activities include: swimming, brisk walking, indoor stationary cycling, step or elliptical machines, and low-impact aerobics (taught by a certified aerobics instructor).