This episode launches the first part of a 3-part mini-series on IBS-C, shedding light on the complexities of this widespread condition that affects millions of people across the U.S. It stresses the importance of a holistic, patient-centered approach to managing IBS-C. We explore the various medications used to treat IBS-C, including both over-the-counter options and prescription drugs, offering a comprehensive review. Our expert guest, Dr. Justin Brandler, a neurogastroenterologist at Virginia Mason Franciscan Health, provides valuable insights into the mechanisms and effectiveness of these treatments.
Dr. Brandler simplifies the intricate science and treatment of IBS into easy-to-understand concepts. He likens his role in treating IBS to that of both a plumber and an electrician. As a disorder of gut-brain interaction (DGBI), IBS affects how the brain and spinal cord process signals, influencing gastrointestinal symptoms.
Different patients respond to different treatment approaches. Dr. Brandler discusses medications that target the "plumbing" aspect of IBS, including pharmaceutical options like linaclotide, tenapanor, and lubiprostone, as well as over-the-counter treatments such as magnesium oxide, senna, and bisacodyl. He also covers treatments that address the altered brain-gut connection in IBS, highlighting various neuromodulators, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), and their role in adjusting the nervous system to help alleviate IBS symptoms.
We explore essential tips for making the most of your medical appointments, such as organizing a concise summary of your medical history and symptoms to ensure clear and effective communication, including outlining your goals. Preparing ahead of time can help your healthcare providers deliver the best possible care and make the right referrals for your needs.
This podcast was sponsored by Ardelyx.
Resources:
Mechanisms of Action Considerations in the Management of IBS-C
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata MPH, RDN (00:18):
This podcast has been sponsored by
Ardelix, or a healthcareprovider, you are in the right
place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome tothe Gut Health Podcast, where we
(00:42):
talk about all things relatedto your gut and well-being.
We are your hosts.
I'm Kate Scarlata, a GIdietitian, and I'm Dr Megan
Riehl, a GI health psychologist.
So we have a new format thatwe're sharing with you today,
and this is a podcast series.
It's a mini -series with threeepisodes.
We're going to take a deeperdive into the diagnosis and
(01:03):
treatment ofconstipation-predominant
irritable bowel syndrome.
Dr. Megan Riehl (01:08):
That's right, Kate, and I really put some
thought and effort into bringingyou experts, including our
expert.
Today we're going to dive intothe subject matter of our book
Mind your Gut and in this firstpart of this IBS series we're
going to talk about the pathwaysto relief.
So, really understandingmedications for the symptom of
(01:29):
constipation, we will beexploring the options from
pharmaceutical toover-the-counter medications and
how they work.
Kate Scarlata MPH, RDN (01:38):
Awesome.
So let's get to it.
Let's introduce our incredibleexpert guest.
He's a good friend and just anamazing clinician that we
really appreciate his approachto care in IBS.
So, Dr Justin Brandler, is amotility expert from Virginia
Mason Franciscan Health inSeattle Washington.
Dr Brandler cares for hispatients with GI conditions,
(02:02):
both complex and general,through evidence-based medicine
and comprehensive personalizedcare plans developed through a
strong patient-physicianpartnership.
He desires to empower patientswith tools for hope and healing.
In addition to usingmedications to treat disease, Dr
Brandler thoughtfully harnessestherapeutic tools from
(02:24):
nutrition yay, psychology,double yay, integrative medicine
and spiritual care.
He strives to earn hispatients' trust and we know the
trust relationship is so huge,especially in IBS and seeks to
provide a safe and welcomingspace through empathetic
listening, humor andcompassionate care.
Dr. Megan Riehl (02:45):
Welcome, Dr Brandler.
Dr. Justin Brandler (02:47):
Thanks you guys so much for having me.
It's like bucket list be on GutHealth Podcast check, so what
an accomplishment.
So thank you so much for havingme.
Kate Scarlata MPH, RDN (02:59):
We're happy to have you.
Dr. Megan Riehl (03:01):
Yes, we were both thrilled as we were
thinking about, like who do wewant to speak on this topic?
And while the point of today isto talk about some of the
pathways to recovery here and tocare, you really approach this.
You walk this with yourpatients and, while medication
can be such an important part ofthe treatment plan, you
(03:24):
certainly bring the holistic tomultidisciplinary care that we
can appreciate from thephysician lens.
Kate Scarlata MPH, RDN (03:32):
And I'll say that Megan mentioned your
name and I was like yes, yes andyes.
He is perfect for this episode.
I was so psyched, so we'rethrilled to have you here beyond
.
Yeah, really happy.
So we're going to dive in.
We're going to start with aneasy one, a nice little softball
for a complex disorder.
(03:52):
So I especially love, probably,the way you describe this to
people to humanize thisdiagnosis.
So tell us what IBS is, howcommon is it and how do we treat
it?
Dr. Justin Brandler (04:03):
How common is it and how do we treat it?
Yeah, so IBS is incrediblycommon, albeit complex, and I
think that's the uniqueness ofit is that every patient that
comes to me so I am aneurogastroenterologist,
motility specialist, brain-gutconnection doctor of which IBS,
or irritable bowel syndrome, isunder the umbrella of these
(04:26):
DGBIs or disorders of gut-braininteraction.
So that's kind of a largeumbrella term, but underneath
that is irritable bowel syndrome, of which there can be a lot of
different what we saypathophysiological, or basically
how your body works and howit's not working well, processes
(04:49):
that can contribute to this.
As far as prevalence, actually,there was a global prevalence
study published in 2020 by theRome Foundation that showed that
up to 40% of the US populationhas a functional GI disease or a
DGBI in general, of which therehave been different estimates,
(05:11):
but around 6% to 8% of the USpopulation has irritable bowel
syndrome, which is a huge numberwhen you think about that.
I mean that's almost 10%, solike one out of 10.
And if you see people lined upat the supermarket waiting for
their self-checkout and there's10 people, one of them probably
has IBS and one of them may beyou.
(05:32):
So it's incredibly common, butincredibly complex and, I think,
needs to be respected as suchwhen we're approaching these
patients.
Dr. Megan Riehl (05:41):
That study you were mentioning.
I love that study and I usethat a lot to highlight and
normalize, and I think, eventaking that 40% a little further
, that group was at a risk ofabout 30%.
So all of the people that haveone DGBI 30% have two DGBIs.
So it really then encompassesupper and lower.
(06:05):
And, just as a kind of FYI forour listeners, the beauty of
many of the things that we'regoing to talk about over the
course of this seriesmedications included, but
lifestyle and nutrition is thatmany of these interventions have
been studied for lower GI, butthey can apply to upper GI
conditions as well.
So I'll use hypnosis as oneexample.
(06:26):
It's just that how we usehypnosis for lower DGBIs urinal
bowel syndrome it can be veryeffective for upper GI.
So not to dive into that toofar today, but just again to
highlight, people are sufferingfrom mouth to anus.
Kate Scarlata MPH, RDN (06:41):
They are , and I would say you know, same
with diet.
There's applications that weuse for IBS that may help with
functional dyspepsia.
That overlap is significant.
Dr. Megan Riehl (06:51):
So what's your elevator pitch, real quick, for
patients that have been newlydiagnosed with IBS.
What do you tell them off thebat?
Dr. Justin Brandler (07:01):
Yeah, I definitely have so many elevator
pitches.
As you guys know, that's kindof my shtick, and I actually
teach a class called Brain GutCoaching Class via Zoom.
That's billable to theirinsurance, because it is so hard
to really do a deeper dive withthese patients in clinic.
We just don't have time and sowe kind of outsource it that way
.
But from a high-level view,what I say is as a brain gut
(07:24):
specialist.
I'm basically a glorifiedplumber and electrician, so I
think about it from a plumbingstandpoint, being a
gastroenterologist.
So the mouth to anus, like howthe bowels, the stomach, the
small bowel, large bowel, thosetypes of things, and sometimes
we target treatments based offplumbing alone, depending upon
(07:45):
the situation.
But there also can be aconnection with the electricity.
So that's where the neuro fitsin, or the neurological nervous
system, and what a deepconnection there is between our
brain and our gut, both withinthe brain's nervous system, both
within the gut's nervous system, called the enteric nervous
(08:07):
system, which is kind of felt tobe maybe a second brain, and
then there's also the connectionin between, which is often the
vagus nerve, if you've heard ofthe vagus nerve as well as some
other nerve pathways.
So that's kind of a high levelview of the physiology, but from
an emotional standpoint, Iguess even before that, I just
(08:28):
sit and look at them and I tellthem I believe you.
I mean honestly, that's thefirst step, or at least I
present that non-verbally,because these conditions are so
challenging, because a lot ofthe testing that we have
currently, or biomarkers, whatwe say can't really capture it.
A lot of times it's the patientwhere their lab studies are
(08:51):
normal, their CT scan is normal,they're shuttled out the door
saying there's nothing wrongwith you, and the patient is
left feeling like nobodybelieves me.
They think it's all in my head,whereas I say an elevator
speech would be it's not all inyour head, but part of it is in
(09:12):
your brain and spinal cordwithin your nervous system.
Because I think if we dototally take away the head piece
, we take off the table so manyhelpful tools that people like
Dr Megan Riehl and others canuse in the psychological realm,
as well as medications, whichwe'll talk about.
Kate Scarlata MPH, RDN (09:32):
Well, I got the chills.
First of all, you know Istarted a campaign, "I Believe
in your Story and so it is sovital and provides just such
trust in that relationship.
When you feel like you'rebelieved, I mean that should be
normal, right, and with a lackof biomarkers and not having
something objective to sink yourteeth in, it does leave
(09:55):
patients feeling a little bitlike what the heck do I have and
do I really have this?
So I'm really glad you saidthat lots of little chills in
your little elevator speech forKate Scarlata.
So let's get into medicaltreatments a little bit, because
we know that at least I've beendoing this for 30 years and the
majority of people that I workwith they don't just require
(10:19):
diet alone.
Some do, some benefit fromgut-directed hypnosis and that's
all they need.
But I feel like the majorityneed like a full toolbox and
medications can, I think,they're stigmatized a little bit
like it's a cop-out, but thesemedications can really be
life-changing and really addressthe plumbing issue in many
(10:40):
cases in constipation.
So can you just go into a deepdive between pharmaceutical
medications as well as some ofthe over-the-counter medications
that people might grab toalleviate some of the
constipation and symptomsassociated with that.
Dr. Justin Brandler (10:56):
Totally.
So diving into a few moremetaphors I use here a bit.
So as far as the toolkit, Ilove the toolkit concept.
I actually use that becauseit's a lot of specialists.
I say I specialize in making alot of friends and maintaining
them because I need their help.
So I think of it as the teamconcept and at Virginia Mason
we're team medicine, sosometimes there are team members
(11:19):
that will be on the field.
So those will be tools that wewill use.
We'll refer to GI dietitians,we'll refer to GI psychologists,
but maybe that's for a time andmaybe they'll go off the field
for a while and we bring in thepelvic floor physical therapist,
for example.
Take them off the bench for aseason because you're a human
being who has a life.
You can't be going to visitsall the time.
(11:40):
So I think the overarching teammetaphor is really helpful when
approaching the toolkit andthen when we dive into the
toolkit for constipation inparticular, I'm actually going
to steal a metaphor from both Dr.
Riehl and my mentor, Bill Chey,who taught me about the
toothpaste metaphor forconstipation.
So I use this all the time,especially before I'm doing a
(12:02):
rectal exam.
So when you think about it,think about a toothpaste tube
with a cap on the bottom.
The cap is the anus and youwant it to loosen well enough to
let the poop out.
You want it to loosen wellenough to let the poop out.
You want it to tighten wellenough to keep the poop in.
So when we focus on the caplevel of management, that can be
a pelvic floor physicaltherapist not even necessarily
(12:24):
medication management.
And a lot of times thesepatients are like I just want to
get better and be done and nomeds and no whatever.
And I'm like okay, well, we dohave to.
There's no magic wand.
That's not a good pitch becausethat's not true.
But if anybody was a magic wand, it would be a pelvic floor
physical therapist, because theycan really help guide you
through a lot of helpfulnon-medicine tools.
(12:46):
But if we go upstream, in thetoothpaste tube metaphor, we can
think of it both from the pastestandpoint as well as from the
tube standpoint.
So from a paste standpoint,soluble fiber can be very
helpful.
However, it's a double-edgedsword, so we want to start low
and go slow.
(13:07):
If we're doing fiber management, the most evidence-based would
be psyllium fiber or metamucil,which is the bright orange
container in the stores, and youcan go week by week, increase
teaspoon by teaspoon to get tothat soft banana stool.
Alternatively, albeit lessevidence-based but helpful for
(13:28):
the bloaters, is citricil.
So it's metabolized a littlebit differently but a little
less bloaty.
So that can be a dietarymanagement.
And also you reach out to yourfriendly GI dietician, bring
them on the field for yourdietary fiber options,
especially maybe lower bloatyfiber options, such as two green
kiwis, which has been studiedin randomized control trials to
(13:50):
be beneficial.
So that's part of the pastemanagement.
Now going up a little level tomore medication management, and
we'll start withover-the-counters.
So one medication that can bereally helpful and people feel
more as kind of a natural optionis magnesium oxide or really
any magnesium product.
I use this all the time now andthere was actually a recent
(14:13):
randomized control trialcomparing it to Senna and it was
equivalent.
We'll talk about Senna in asecond.
But magnesium oxide can behelpful for a few reasons.
It's called an osmotic laxative, so it can help to kind of
soften that paste a little bit.
Also, to a certain degree themagnesium can have a muscle
relaxant effect as well, as alot of my patients have benefit
(14:37):
with sleep if they take it atnight, so it can kind of serve a
lot of different modalities.
You want to get it from areputable company that's been
third-party tested so it has theright amount of magnesium, and
you want to avoid it if you havechronic kidney disease, but for
the vast majority of peopleit's incredibly safe and
effective.
Kate Scarlata MPH, RDN (14:57):
Can I just interject like where do you
start with magnesium?
Do you start at a certain dose?
Dr. Justin Brandler (15:02):
So what I tell them is magnesium oxide,
400 milligrams, because that'show it's been most studied and I
started at one a day andoftentimes I advise them at
night because of that sleepbenefit and then we can increase
each week.
We say at night and then maybein the morning, and then it's
even been studied up to threetimes a day.
1,200 milligrams is perfectlysafe for people.
(15:25):
Now there are so many magnesiumproducts and it is insanely
confusing.
I kind of try to center them onoxide because it's a little bit
more of a nice balance betweenabsorption by the GI tract and
getting those blood levelshigher which can help the sleep
medicine.
But it also stays within thebowel to help that stool
(15:47):
softening effect, as opposed tolike magnesium citrate which
theoretically maybe stays morein the bowel and has a bit more
cramping effect for some peoplenot always but some and then on
the other end is like magnesiumglycinate, for example.
That's absorbed more by the GItract and has a bit more
evidence for like headaches andsleep and stuff like that but
(16:09):
may not have as muchconstipation benefit.
But it really unfortunately isa bit of trial and error and I
have patients along the spectrumand we just kind of go with
what works.
So as far as other pasteoptions, miralax, you know, is a
tried and true.
That's usually in a whitecontainer with a purple cap at
the store over the counter, youknow, generally relatively safe.
(16:32):
You know, there is someevidence that's starting to
develop in terms of long-termside effects when you've been on
it for a long time, potentiallyfrom a neuropsychiatric
standpoint.
That evidence still has toevolve more and especially in my
little old lady who's like 70or 80, that I'm like that is a
long-term consequence.
I don't care about that for you, I just want you to be feeling
(16:56):
better.
And the other trick here isit's recommended as a full
capful.
Sometimes that's too much andthat gets you too liquidy.
You can always break the rulesa little bit and go to a half
capful.
It's not against the law,nobody's going to come and get
you so and that can actually beall that's needed.
(17:16):
And then there are a few otherones, you know docusate, which
is like a stool softener.
Actually pretty minimalevidence there one of my friends
when I was at Mayo, AllisonYang, who's now in the Harvard
system, I believe, she describedit as all mush, no push.
(17:36):
So it really just softens thestool, which can be really
helpful for somebody who doesn'thave motility issues, but it's
more of a you know, they have ananal fissure, for example, and
they just really want to getsomething smooth by that anal
fissure.
That can be a helpful tool.
So you know, that's kind of abird's eye view.
I think of the paste type ofinterventions where we can help
soften the stool.
That's more in the osmoticlaxative category.
(18:00):
I guess.
Another one if we're going to goin prescriptions and we're
going to stay in the paste worldnow we're going to enter into
the prescription medicines.
So that's something likelinaclotide, for example, or
Linzess.
Another one is lubiprostone oramitiza.
I actually don't like that oneas much because it has a high
risk of nausea, althoughinsurance loves to force you to
(18:22):
go through that because it'scheaper.
And then another one isplacanotide or trulence.
Basically all three of thosework in a very similar mechanism
.
Lubiprostone's a littledifferent but essentially it
helps to secrete fluid from thesmall bowel into the large bowel
and out.
And especially linaclotide andplacanotide and I guess
(18:47):
lubiprostone to a certain extentare indicated for both chronic
idiopathic constipation sothat's constipation without the
pain as well as IBS withconstipation, which is
constipation with the pain, andhow we think that works maybe is
through affecting the painreceptors and helping those numb
those down a bit.
(19:07):
So those are some prescriptionoptions in that realm.
Another new kid on the blockwhich is pretty exciting is
tenapanor or Ibsrela, so thatone is indicated for IBS with
constipation predominance, andit actually is a totally new
mechanism of action that we kindof think is almost a
(19:27):
retainagogue.
So as opposed to secretagogueswhere they secrete fluid, this
one actually blocks a certainreceptor to keep fluid or retain
the fluid within the smallbowel so that it comes out and
in some ways maybe a little lessdiarrhea side effect with this
guy as well, as if you hang onto it for six to eight weeks or
(19:48):
so that's how it was studiedwhere we get some bloating and
pain benefit but you can startto get the stool consistency
benefit off the bat.
So that's a lot of paced stuffboth from OTCs over the counters
as well as to prescription.
Now going out to the tubeitself tube itself.
Advertisement (20:15):
Are you taking a prescription medicine for
irritable bowel syndrome withconstipation or IBS-C?
If symptoms like constipation,belly pain and bloating are
still bothering you, it may betime to try something different.
Ibsrela (Tenapanor) is aprescription medicine used to
treat adults with IBS-C.
Ibsrela works differently torelieve the symptoms of IBS-C,
(20:59):
so you can focus on what'simportant to you.
Ask your doctor if Ibsrelacould be right for you IBS-C.
Okay, so we're going to talkabout things.
Ready to try somethingdifferent for your IBS-C
symptoms?
Ask your doctor about Ibsrela.
Dr. Justin Brandler (21:18):
Okay.
So we're going to talk aboutthings that can squeeze the tube
, so we think about them likestimulant laxatives.
We'll start at over-the-counterlevel.
So over-the-counter level wouldbe something like your senna or
Senok ot, so senna is actuallyderived from plants and actually
can be very helpful in terms ofstimulating the bowels.
Sometimes there can be a bit ofcramping here, though, so I
would start at just like one taband test it out.
(21:41):
You can go up to even two tabstwice a day.
Another fun little trick is forthose tea drinkers out there is
smooth move tea actually, soyou can steep a tea bag at night
, have some of that stimulationhappening over the nighttime, so
hopefully avoiding some of thecramping, and then ideal world
(22:01):
is wake up with a beautifulbanana bowel movement.
That is definitely ideal, yeah,that is always the goal, doesn't
necessarily always happen, butI think a reasonable strategy,
especially for people lookingfor that natural option.
Another one in the realm of thesqueezers is bisacodyl or
Dulcolax.
I will tell you this isinsanely confusing when you're
(22:23):
going to the store because thereare Docusate, which is the
stool softener, the all mush, nopush, and the Dulcolax, which
is actually the brand name thatmakes the bisacodyl.
I think they also do docusate.
So it's insanely confusing.
But if you're looking for thetrue ingredient, when you're
looking on the back, look forbisacodyl B-I-S-A-C-O-D-Y-L.
(22:47):
Now that's actually a littlebit more effective stimulant
laxative and I do advise it tostart with five milligrams.
But this can be reallyeffective, especially for our
patients.
Without the pain component.
It's more the constipationbecause the stimulation isn't
going to bother them as much.
I don't use it as much for myIBS-C patients because until we
(23:11):
get that turned down in terms ofthe pain, we may not have as
much benefit and more sideeffect.
Dr. Megan Riehl (23:17):
That's a good point.
Just to make that, you know, atenant of IBS is abdominal pain
plus these bowel fluctuations.
But there are lots of types ofconstipation too, so you can
have constipation withoutabdominal pain and, to your
point, talking about that withyour gastroenterologist or
primary care physician is reallygoing to help inform many of
(23:37):
the treatment suggestions thatthey make you got it.
Dr. Justin Brandler (23:40):
It's all pain, no gain of IBS diagnosis.
So it's a little differentflavor there and different
strategies.
And then finally anothersomewhat newer kid on the block
for a stimul.
Block for a prokinetic we wouldsay, is prucalopride or
Motegrity, so that one canstimulate the bowels, albeit in
a more gentle fashion.
However, it's technicallyindicated more for chronic
(24:02):
idiopathic constipation, so kindof avoiding it with those with
pain.
So that's really we're divinginto all the plumbing stuff.
I don't know how much we wantto go into the electricity stuff
as far as neuromodulators, butin general for an IBS-C patient
I'm going to focus on theplumbing first actually, because
sometimes getting the plumbingin order, whatever that looks
(24:24):
like, you know paste, tube orcap strategies that may help the
pain just secondarily and wedon't even need to go into the
electricity realm of theneuromodulators where we're
adjusting the nervous system.
That's kind of a bird's eyeview of the pharmaceutical
approaches.
Kate Scarlata MPH, RDN (24:42):
That's awesome.
I learned a lot, you know, andI feel like I knew the drugs
pretty well, but the way youworded it is just so simple.
That was great, thank you.
Dr. Megan Riehl (24:51):
Dr Brandler just very briefly tell us a
little bit about whatneuromodulators mean and what a
patient that's struggling withconstipation might get in terms
of a prescription.
Dr. Justin Brandler (25:01):
Totally.
As I said, we'll focus a bitmore on plumbing first, but this
is in the electricity.
So neuromodulator means changeor modulate the nervous system.
And yes, these drugs originallywere antidepressants,
anti-anxiety, but a lot of timeswe use them in different ways
with these conditions.
So, for an example, SSRIs cansometimes be used for patients
(25:26):
that have predominant anxietyand depression features, and
actually it's because weleverage the side effects to a
certain extent.
A lot of times diarrhea can bea side effect which we can
totally leverage for aconstipated patient, right.
So something like a sertraline,for example, Zoloft we can get
by with low dose for that andthat can help calm or settle
(25:48):
down the nervous system to acertain extent.
Now, with our bigger pain people, I would actually recommend
more a SNRI for my constipatedpain patients.
So that's serotonin andnorepinephrine.
The one I love the most by faris duloxetine or Cymbalta.
It can be incredibly effectiveand treats so many different
(26:10):
things, including the pain for alot of conditions depression
and anxiety and has less of aside effect profile, especially
constipation.
Finally, tricyclics ortricyclic antidepressants
actually have the most evidenceand we use them in much lower
doses.
This is like amitriptyline ornortriptyline I would use in a
(26:31):
constipated patient because itdoesn't pass the blood-brain
barrier as much.
But that does have aconstipating side effect.
So I'd want to get the plumbingdown under control first, and
then we move into the tricyclics.
Kate Scarlata MPH, RDN (26:42):
Thanks for that.
You know, I think of people.
They hear neuromodulation (andthink).
.
.
this is used for depression.
My doctor thinks I havedepression.
What is your elevator speechabout that?
Dr. Justin Brandler (26:54):
I go back to.
It's not all in your head, butpart of it is in your nervous
system and in your brain andspinal cord and the way that we
know these work actually andthrough the class I'm able to
teach this more but we areunderstanding more about these
pathways and actually how it canhelp to control those
overactive gut to brainsignaling.
And the other thing is we canactually get by with lower doses
(27:17):
for brain gut conditions thanwe actually do for full-blown
mental health conditions.
So that's also why in some waysI'm like, hey, whatever, I'm
not even going to put anxietydepression in your chart,
because I actually don't eventhink you're anxious or
depressed, I just think yournervous system's all out of
whack and let's turn it down.
So you know, that's alsosometimes how it can be framed
(27:38):
too.
Dr. Megan Riehl (27:39):
Perfect, and people aren't going to be
usually on these for the rest oftheir life too, and therefore
having these additionalfollow-up appointments with you
to talk about their hopefullyimprovements can help them
inform future treatment.
So, from that kind oftransition, tell us what is the
(28:00):
most beneficial information thata patient can prepare to make
the most of their time with aneurogastroenterologist or
somebody like you.
Dr. Justin Brandler (28:11):
Yeah, I mean, I think first of all is
they're probably not going tosee a neurogastroenterologist,
right?
They're going to see a generalgastroenterologist, a general GI
, nurse practitioner or PA thatalso probably really care, but
they're very limited on time.
So one of the best advice I cangive you is really go in with a
good sense of what your goalsand expectations are for the
(28:34):
appointment, Because,inadvertently, what often
happens is you're suffering,right, you don't, you just want
to feel better and that's allyou want to feel.
But that's very hard for theperson on the other end of the
exam room to address withoutreally understanding what you're
looking at, what your goals are, because there's only so much
time to cover, I will say,actually a shameless plug for a
(28:57):
talk I gave a few years ago withthe IFFGD or International
Foundation for GI Disorders,which you can still find online
actually, I saw is I gave a talkcalled Living Your Best IBS
Life and in that I give you aguide of an IBS snapshot, so a
(29:17):
one-page summary of the keypoints that you can give to your
provider that you're seeing,and I will tell you if you can
summarize in a page your basichistory of your predominant
stool habits, if you're speakingthe Bristol stool chart, for
example, if you're identifyingsome of your triggers, if you're
doing those types of things, ifyou can give a one-page summary
(29:40):
, as opposed to a giant binderor a giga download of your
tracker's PDF or whatever,that's going to go so much
farther and that provider isgoing to feel so much more
empowered themselves to empoweryou with guidance as to next
steps.
So key goals and expectationsfor that visit and then
(30:00):
organizing your thoughts andhistory into a one-page summary,
if at all possible, is really,really ideal.
Kate Scarlata MPH, RDN (30:08):
Yeah, I often say like of all the
symptoms you're experiencing,try to kind of like qualify
those.
.
.
Like bloating is the mostdifficult, or pain is the most
difficult, or I'm in the toiletfor 14 hours every morning is
the most difficult.
So the physician can kind ofprioritize right and you're on
the same page.
Dr. Justin Brandler (30:27):
And quality of life too, like what of these
constellation of symptoms mostaffects your quality of life,
and that we can more precisiontarget, because from there a lot
of other things will fall inplace, because a lot of this
these aren't quantity of lifeconditions, these are quality of
life conditions, and so if wecan really focus on and pinpoint
(30:48):
the takeaway from that, thenthat can really lead to
high-yield visits.
Dr. Megan Riehl (30:53):
And Kate and I will talk more about this in
part two, but just off the topof our head again, if this is a
plumbing issue and you're tryinga bunch of different
medications over the counter andyou're just not sure and you
want some clarity, then havingthat medical provider
conversation is so important.
If you are avoiding going tothings with your family, if
(31:14):
you're at home, your avoidancebehaviors, your stress, your
anxiety, you are depressedbecause of your symptoms, that's
going to key in our physiciancolleague to make that consult
to a GI mental health provider.
Or if you're afraid to eat, youdon't know what to eat, you are
avoiding meals again it's goingto trigger that referral to a
(31:35):
GI dietician.
So it's really important againto be organized and to be open
with your physician so that theycan help guide where to go next
.
Kate Scarlata MPH, RDN (31:46):
And I would add you know, sometimes
you try a treatment, you see thedoctor and you say I feel
better, but the doctor doesn'tunderstand necessarily like how
better?
Like sometimes you try atreatment, you see the doctor
and you say I feel better, butthe doctor doesn't understand
necessarily like how better,like are you at 80% of where you
want to be, or is it you werezero and now you're 10?
Dr. Justin Brandler (32:01):
So sometimes making sure you kind
of qualify the benefits that youreceived, Actually, in my
practice now we're collectingIBS symptom severity scores so
objective scores at thebeginning, and then we see that
progress.
And it's actually so rewardingfor myself that we just talked
about this yesterday with apatient.
She went from like 330 to like20 or something.
(32:22):
It was amazing.
So rewarding for our teammembers too.
Sometimes we do mental healthscores as well to objectively
see those changes.
Sometimes we do mental healthscores as well to objectively
see those changes.
So you can work with yourprovider on how to do that,
maybe even do that beforehandfor them so that they know where
things are at.
Kate Scarlata MPH, RDN (32:38):
Well, this was amazing, and no
surprise, because you're amazing.
I couldn't have wanted a betterscenario for this episode.
.
.
you covered, from A to Z andreally understanding medications
better and the complexity ofIBS, and I love the plumbing,
electrical sort of systemalterations that are associated
(33:00):
in very simplistic terms for ourlisteners.
So thanks for your time.
Dr. Justin Brandler (33:05):
Yeah, thank you guys so much for having me.
I mean, I just like, blow up,Mind Your Gut with patients, I
mean as they're waiting to seeme.
I'm like, okay, this issomething you can read before
seeing me.
Like it's, it's promoted in theclasses, like it's just, you
guys provided such a powerfultool that I've read myself that,
as you know, that is verypatient, accessible and myth
(33:26):
busty, which is also incrediblyimportant, and a side
conversation.
So, thank you guys so much forwhat you're doing for patients
everywhere.
Dr. Megan Riehl (33:34):
Well, we look forward to ongoing collaboration
with such a rock star in themotility space and everybody out
there listening.
Please make sure that yousubscribe, like and follow The
Gut Health Podcast.
Your support means the world tous, our friends.
Kate Scarlata MPH, RDN (33:51):
Thanks everyone.
Dr. Megan Riehl (33:53):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at The Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
This podcast has been sponsored by
Ardelix, or a healthcareprovider, you are in the right
place.
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Hello, friends, and welcome tothe Gut Health Podcast, where we
(00:42):
talk about all things relatedto your gut and well-being.
We are your hosts.
I'm Kate Scarlata, a GIdietitian, and I'm Dr Megan
Riehl, a GI health psychologist.
So we have a new format thatwe're sharing with you today,
and this is a podcast series.
It's a mini -series with threeepisodes.
We're going to take a deeperdive into the diagnosis and
(01:03):
treatment ofconstipation-predominant
irritable bowel syndrome.
Dr. Megan Riehl (01:08):
That's right, Kate, and I really put some
thought and effort into bringingyou experts, including our
expert.
Today we're going to dive intothe subject matter of our book
Mind your Gut and in this firstpart of this IBS series we're
going to talk about the pathwaysto relief.
So, really understandingmedications for the symptom of
(01:29):
constipation, we will beexploring the options from
pharmaceutical toover-the-counter medications and
how they work.
Kate Scarlata MPH, RDN (01:38):
Awesome.
So let's get to it.
Let's introduce our incredibleexpert guest.
He's a good friend and just anamazing clinician that we
really appreciate his approachto care in IBS.
So, Dr Justin Brandler, is amotility expert from Virginia
Mason Franciscan Health inSeattle Washington.
Dr Brandler cares for hispatients with GI conditions,
(02:02):
both complex and general,through evidence-based medicine
and comprehensive personalizedcare plans developed through a
strong patient-physicianpartnership.
He desires to empower patientswith tools for hope and healing.
In addition to usingmedications to treat disease, Dr
Brandler thoughtfully harnessestherapeutic tools from
(02:24):
nutrition yay, psychology,double yay, integrative medicine
and spiritual care.
He strives to earn hispatients' trust and we know the
trust relationship is so huge,especially in IBS and seeks to
provide a safe and welcomingspace through empathetic
listening, humor andcompassionate care.
Dr. Megan Riehl (02:45):
Welcome, Dr Brandler.
Dr. Justin Brandler (02:47):
Thanks you guys so much for having me.
It's like bucket list be on GutHealth Podcast check, so what
an accomplishment.
So thank you so much for havingme.
Kate Scarlata MPH, RDN (02:59):
We're happy to have you.
Dr. Megan Riehl (03:01):
Yes, we were both thrilled as we were
thinking about, like who do wewant to speak on this topic?
And while the point of today isto talk about some of the
pathways to recovery here and tocare, you really approach this.
You walk this with yourpatients and, while medication
can be such an important part ofthe treatment plan, you
(03:24):
certainly bring the holistic tomultidisciplinary care that we
can appreciate from thephysician lens.
Kate Scarlata MPH, RDN (03:32):
And I'll say that Megan mentioned your
name and I was like yes, yes andyes.
He is perfect for this episode.
I was so psyched, so we'rethrilled to have you here beyond
.
Yeah, really happy.
So we're going to dive in.
We're going to start with aneasy one, a nice little softball
for a complex disorder.
(03:52):
So I especially love, probably,the way you describe this to
people to humanize thisdiagnosis.
So tell us what IBS is, howcommon is it and how do we treat
it?
Dr. Justin Brandler (04:03):
How common is it and how do we treat it?
Yeah, so IBS is incrediblycommon, albeit complex, and I
think that's the uniqueness ofit is that every patient that
comes to me so I am aneurogastroenterologist,
motility specialist, brain-gutconnection doctor of which IBS,
or irritable bowel syndrome, isunder the umbrella of these
(04:26):
DGBIs or disorders of gut-braininteraction.
So that's kind of a largeumbrella term, but underneath
that is irritable bowel syndrome, of which there can be a lot of
different what we saypathophysiological, or basically
how your body works and howit's not working well, processes
(04:49):
that can contribute to this.
As far as prevalence, actually,there was a global prevalence
study published in 2020 by theRome Foundation that showed that
up to 40% of the US populationhas a functional GI disease or a
DGBI in general, of which therehave been different estimates,
(05:11):
but around 6% to 8% of the USpopulation has irritable bowel
syndrome, which is a huge numberwhen you think about that.
I mean that's almost 10%, solike one out of 10.
And if you see people lined upat the supermarket waiting for
their self-checkout and there's10 people, one of them probably
has IBS and one of them may beyou.
(05:32):
So it's incredibly common, butincredibly complex and, I think,
needs to be respected as suchwhen we're approaching these
patients.
Dr. Megan Riehl (05:41):
That study you were mentioning.
I love that study and I usethat a lot to highlight and
normalize, and I think, eventaking that 40% a little further
, that group was at a risk ofabout 30%.
So all of the people that haveone DGBI 30% have two DGBIs.
So it really then encompassesupper and lower.
(06:05):
And, just as a kind of FYI forour listeners, the beauty of
many of the things that we'regoing to talk about over the
course of this seriesmedications included, but
lifestyle and nutrition is thatmany of these interventions have
been studied for lower GI, butthey can apply to upper GI
conditions as well.
So I'll use hypnosis as oneexample.
(06:26):
It's just that how we usehypnosis for lower DGBIs urinal
bowel syndrome it can be veryeffective for upper GI.
So not to dive into that toofar today, but just again to
highlight, people are sufferingfrom mouth to anus.
Kate Scarlata MPH, RDN (06:41):
They are , and I would say you know, same
with diet.
There's applications that weuse for IBS that may help with
functional dyspepsia.
That overlap is significant.
Dr. Megan Riehl (06:51):
So what's your elevator pitch, real quick, for
patients that have been newlydiagnosed with IBS.
What do you tell them off thebat?
Dr. Justin Brandler (07:01):
Yeah, I definitely have so many elevator
pitches.
As you guys know, that's kindof my shtick, and I actually
teach a class called Brain GutCoaching Class via Zoom.
That's billable to theirinsurance, because it is so hard
to really do a deeper dive withthese patients in clinic.
We just don't have time and sowe kind of outsource it that way
.
But from a high-level view,what I say is as a brain gut
(07:24):
specialist.
I'm basically a glorifiedplumber and electrician, so I
think about it from a plumbingstandpoint, being a
gastroenterologist.
So the mouth to anus, like howthe bowels, the stomach, the
small bowel, large bowel, thosetypes of things, and sometimes
we target treatments based offplumbing alone, depending upon
(07:45):
the situation.
But there also can be aconnection with the electricity.
So that's where the neuro fitsin, or the neurological nervous
system, and what a deepconnection there is between our
brain and our gut, both withinthe brain's nervous system, both
within the gut's nervous system, called the enteric nervous
(08:07):
system, which is kind of felt tobe maybe a second brain, and
then there's also the connectionin between, which is often the
vagus nerve, if you've heard ofthe vagus nerve as well as some
other nerve pathways.
So that's kind of a high levelview of the physiology, but from
an emotional standpoint, Iguess even before that, I just
(08:28):
sit and look at them and I tellthem I believe you.
I mean honestly, that's thefirst step, or at least I
present that non-verbally,because these conditions are so
challenging, because a lot ofthe testing that we have
currently, or biomarkers, whatwe say can't really capture it.
A lot of times it's the patientwhere their lab studies are
(08:51):
normal, their CT scan is normal,they're shuttled out the door
saying there's nothing wrongwith you, and the patient is
left feeling like nobodybelieves me.
They think it's all in my head,whereas I say an elevator
speech would be it's not all inyour head, but part of it is in
(09:12):
your brain and spinal cordwithin your nervous system.
Because I think if we dototally take away the head piece
, we take off the table so manyhelpful tools that people like
Dr Megan Riehl and others canuse in the psychological realm,
as well as medications, whichwe'll talk about.
Kate Scarlata MPH, RDN (09:32):
Well, I got the chills.
First of all, you know Istarted a campaign, "I Believe
in your Story and so it is sovital and provides just such
trust in that relationship.
When you feel like you'rebelieved, I mean that should be
normal, right, and with a lackof biomarkers and not having
something objective to sink yourteeth in, it does leave
(09:55):
patients feeling a little bitlike what the heck do I have and
do I really have this?
So I'm really glad you saidthat lots of little chills in
your little elevator speech forKate Scarlata.
So let's get into medicaltreatments a little bit, because
we know that at least I've beendoing this for 30 years and the
majority of people that I workwith they don't just require
(10:19):
diet alone.
Some do, some benefit fromgut-directed hypnosis and that's
all they need.
But I feel like the majorityneed like a full toolbox and
medications can, I think,they're stigmatized a little bit
like it's a cop-out, but thesemedications can really be
life-changing and really addressthe plumbing issue in many
(10:40):
cases in constipation.
So can you just go into a deepdive between pharmaceutical
medications as well as some ofthe over-the-counter medications
that people might grab toalleviate some of the
constipation and symptomsassociated with that.
Dr. Justin Brandler (10:56):
Totally.
So diving into a few moremetaphors I use here a bit.
So as far as the toolkit, Ilove the toolkit concept.
I actually use that becauseit's a lot of specialists.
I say I specialize in making alot of friends and maintaining
them because I need their help.
So I think of it as the teamconcept and at Virginia Mason
we're team medicine, sosometimes there are team members
(11:19):
that will be on the field.
So those will be tools that wewill use.
We'll refer to GI dietitians,we'll refer to GI psychologists,
but maybe that's for a time andmaybe they'll go off the field
for a while and we bring in thepelvic floor physical therapist,
for example.
Take them off the bench for aseason because you're a human
being who has a life.
You can't be going to visitsall the time.
(11:40):
So I think the overarching teammetaphor is really helpful when
approaching the toolkit andthen when we dive into the
toolkit for constipation inparticular, I'm actually going
to steal a metaphor from both Dr.
Riehl and my mentor, Bill Chey,who taught me about the
toothpaste metaphor forconstipation.
So I use this all the time,especially before I'm doing a
(12:02):
rectal exam.
So when you think about it,think about a toothpaste tube
with a cap on the bottom.
The cap is the anus and youwant it to loosen well enough to
let the poop out.
You want it to loosen wellenough to let the poop out.
You want it to tighten wellenough to keep the poop in.
So when we focus on the caplevel of management, that can be
a pelvic floor physicaltherapist not even necessarily
(12:24):
medication management.
And a lot of times thesepatients are like I just want to
get better and be done and nomeds and no whatever.
And I'm like okay, well, we dohave to.
There's no magic wand.
That's not a good pitch becausethat's not true.
But if anybody was a magic wand, it would be a pelvic floor
physical therapist, because theycan really help guide you
through a lot of helpfulnon-medicine tools.
(12:46):
But if we go upstream, in thetoothpaste tube metaphor, we can
think of it both from the pastestandpoint as well as from the
tube standpoint.
So from a paste standpoint,soluble fiber can be very
helpful.
However, it's a double-edgedsword, so we want to start low
and go slow.
(13:07):
If we're doing fiber management, the most evidence-based would
be psyllium fiber or metamucil,which is the bright orange
container in the stores, and youcan go week by week, increase
teaspoon by teaspoon to get tothat soft banana stool.
Alternatively, albeit lessevidence-based but helpful for
(13:28):
the bloaters, is citricil.
So it's metabolized a littlebit differently but a little
less bloaty.
So that can be a dietarymanagement.
And also you reach out to yourfriendly GI dietician, bring
them on the field for yourdietary fiber options,
especially maybe lower bloatyfiber options, such as two green
kiwis, which has been studiedin randomized control trials to
(13:50):
be beneficial.
So that's part of the pastemanagement.
Now going up a little level tomore medication management, and
we'll start withover-the-counters.
So one medication that can bereally helpful and people feel
more as kind of a natural optionis magnesium oxide or really
any magnesium product.
I use this all the time now andthere was actually a recent
(14:13):
randomized control trialcomparing it to Senna and it was
equivalent.
We'll talk about Senna in asecond.
But magnesium oxide can behelpful for a few reasons.
It's called an osmotic laxative, so it can help to kind of
soften that paste a little bit.
Also, to a certain degree themagnesium can have a muscle
relaxant effect as well, as alot of my patients have benefit
(14:37):
with sleep if they take it atnight, so it can kind of serve a
lot of different modalities.
You want to get it from areputable company that's been
third-party tested so it has theright amount of magnesium, and
you want to avoid it if you havechronic kidney disease, but for
the vast majority of peopleit's incredibly safe and
effective.
Kate Scarlata MPH, RDN (14:57):
Can I just interject like where do you
start with magnesium?
Do you start at a certain dose?
Dr. Justin Brandler (15:02):
So what I tell them is magnesium oxide,
400 milligrams, because that'show it's been most studied and I
started at one a day andoftentimes I advise them at
night because of that sleepbenefit and then we can increase
each week.
We say at night and then maybein the morning, and then it's
even been studied up to threetimes a day.
1,200 milligrams is perfectlysafe for people.
(15:25):
Now there are so many magnesiumproducts and it is insanely
confusing.
I kind of try to center them onoxide because it's a little bit
more of a nice balance betweenabsorption by the GI tract and
getting those blood levelshigher which can help the sleep
medicine.
But it also stays within thebowel to help that stool
(15:47):
softening effect, as opposed tolike magnesium citrate which
theoretically maybe stays morein the bowel and has a bit more
cramping effect for some peoplenot always but some and then on
the other end is like magnesiumglycinate, for example.
That's absorbed more by the GItract and has a bit more
evidence for like headaches andsleep and stuff like that but
(16:09):
may not have as muchconstipation benefit.
But it really unfortunately isa bit of trial and error and I
have patients along the spectrumand we just kind of go with
what works.
So as far as other pasteoptions, miralax, you know, is a
tried and true.
That's usually in a whitecontainer with a purple cap at
the store over the counter, youknow, generally relatively safe.
(16:32):
You know, there is someevidence that's starting to
develop in terms of long-termside effects when you've been on
it for a long time, potentiallyfrom a neuropsychiatric
standpoint.
That evidence still has toevolve more and especially in my
little old lady who's like 70or 80, that I'm like that is a
long-term consequence.
I don't care about that for you, I just want you to be feeling
(16:56):
better.
And the other trick here isit's recommended as a full
capful.
Sometimes that's too much andthat gets you too liquidy.
You can always break the rulesa little bit and go to a half
capful.
It's not against the law,nobody's going to come and get
you so and that can actually beall that's needed.
(17:16):
And then there are a few otherones, you know docusate, which
is like a stool softener.
Actually pretty minimalevidence there one of my friends
when I was at Mayo, AllisonYang, who's now in the Harvard
system, I believe, she describedit as all mush, no push.
(17:36):
So it really just softens thestool, which can be really
helpful for somebody who doesn'thave motility issues, but it's
more of a you know, they have ananal fissure, for example, and
they just really want to getsomething smooth by that anal
fissure.
That can be a helpful tool.
So you know, that's kind of abird's eye view.
I think of the paste type ofinterventions where we can help
soften the stool.
That's more in the osmoticlaxative category.
(18:00):
I guess.
Another one if we're going to goin prescriptions and we're
going to stay in the paste worldnow we're going to enter into
the prescription medicines.
So that's something likelinaclotide, for example, or
Linzess.
Another one is lubiprostone oramitiza.
I actually don't like that oneas much because it has a high
risk of nausea, althoughinsurance loves to force you to
(18:22):
go through that because it'scheaper.
And then another one isplacanotide or trulence.
Basically all three of thosework in a very similar mechanism
.
Lubiprostone's a littledifferent but essentially it
helps to secrete fluid from thesmall bowel into the large bowel
and out.
And especially linaclotide andplacanotide and I guess
(18:47):
lubiprostone to a certain extentare indicated for both chronic
idiopathic constipation sothat's constipation without the
pain as well as IBS withconstipation, which is
constipation with the pain, andhow we think that works maybe is
through affecting the painreceptors and helping those numb
those down a bit.
(19:07):
So those are some prescriptionoptions in that realm.
Another new kid on the blockwhich is pretty exciting is
tenapanor or Ibsrela, so thatone is indicated for IBS with
constipation predominance, andit actually is a totally new
mechanism of action that we kindof think is almost a
(19:27):
retainagogue.
So as opposed to secretagogueswhere they secrete fluid, this
one actually blocks a certainreceptor to keep fluid or retain
the fluid within the smallbowel so that it comes out and
in some ways maybe a little lessdiarrhea side effect with this
guy as well, as if you hang onto it for six to eight weeks or
(19:48):
so that's how it was studiedwhere we get some bloating and
pain benefit but you can startto get the stool consistency
benefit off the bat.
So that's a lot of paced stuffboth from OTCs over the counters
as well as to prescription.
Now going out to the tubeitself tube itself.
Advertisement (20:15):
Are you taking a prescription medicine for
irritable bowel syndrome withconstipation or IBS-C?
If symptoms like constipation,belly pain and bloating are
still bothering you, it may betime to try something different.
Ibsrela (Tenapanor) is aprescription medicine used to
treat adults with IBS-C.
Ibsrela works differently torelieve the symptoms of IBS-C,
(20:59):
so you can focus on what'simportant to you.
Ask your doctor if Ibsrelacould be right for you IBS-C.
Okay, so we're going to talkabout things.
Ready to try somethingdifferent for your IBS-C
symptoms?
Ask your doctor about Ibsrela.
Dr. Justin Brandler (21:18):
Okay.
So we're going to talk aboutthings that can squeeze the tube
, so we think about them likestimulant laxatives.
We'll start at over-the-counterlevel.
So over-the-counter level wouldbe something like your senna or
Senok ot, so senna is actuallyderived from plants and actually
can be very helpful in terms ofstimulating the bowels.
Sometimes there can be a bit ofcramping here, though, so I
would start at just like one taband test it out.
(21:41):
You can go up to even two tabstwice a day.
Another fun little trick is forthose tea drinkers out there is
smooth move tea actually, soyou can steep a tea bag at night
, have some of that stimulationhappening over the nighttime, so
hopefully avoiding some of thecramping, and then ideal world
(22:01):
is wake up with a beautifulbanana bowel movement.
That is definitely ideal, yeah,that is always the goal, doesn't
necessarily always happen, butI think a reasonable strategy,
especially for people lookingfor that natural option.
Another one in the realm of thesqueezers is bisacodyl or
Dulcolax.
I will tell you this isinsanely confusing when you're
(22:23):
going to the store because thereare Docusate, which is the
stool softener, the all mush, nopush, and the Dulcolax, which
is actually the brand name thatmakes the bisacodyl.
I think they also do docusate.
So it's insanely confusing.
But if you're looking for thetrue ingredient, when you're
looking on the back, look forbisacodyl B-I-S-A-C-O-D-Y-L.
(22:47):
Now that's actually a littlebit more effective stimulant
laxative and I do advise it tostart with five milligrams.
But this can be reallyeffective, especially for our
patients.
Without the pain component.
It's more the constipationbecause the stimulation isn't
going to bother them as much.
I don't use it as much for myIBS-C patients because until we
(23:11):
get that turned down in terms ofthe pain, we may not have as
much benefit and more sideeffect.
Dr. Megan Riehl (23:17):
That's a good point.
Just to make that, you know, atenant of IBS is abdominal pain
plus these bowel fluctuations.
But there are lots of types ofconstipation too, so you can
have constipation withoutabdominal pain and, to your
point, talking about that withyour gastroenterologist or
primary care physician is reallygoing to help inform many of
(23:37):
the treatment suggestions thatthey make you got it.
Dr. Justin Brandler (23:40):
It's all pain, no gain of IBS diagnosis.
So it's a little differentflavor there and different
strategies.
And then finally anothersomewhat newer kid on the block
for a stimul.
Block for a prokinetic we wouldsay, is prucalopride or
Motegrity, so that one canstimulate the bowels, albeit in
a more gentle fashion.
However, it's technicallyindicated more for chronic
(24:02):
idiopathic constipation, so kindof avoiding it with those with
pain.
So that's really we're divinginto all the plumbing stuff.
I don't know how much we wantto go into the electricity stuff
as far as neuromodulators, butin general for an IBS-C patient
I'm going to focus on theplumbing first actually, because
sometimes getting the plumbingin order, whatever that looks
(24:24):
like, you know paste, tube orcap strategies that may help the
pain just secondarily and wedon't even need to go into the
electricity realm of theneuromodulators where we're
adjusting the nervous system.
That's kind of a bird's eyeview of the pharmaceutical
approaches.
Kate Scarlata MPH, RDN (24:42):
That's awesome.
I learned a lot, you know, andI feel like I knew the drugs
pretty well, but the way youworded it is just so simple.
That was great, thank you.
Dr. Megan Riehl (24:51):
Dr Brandler just very briefly tell us a
little bit about whatneuromodulators mean and what a
patient that's struggling withconstipation might get in terms
of a prescription.
Dr. Justin Brandler (25:01):
Totally.
As I said, we'll focus a bitmore on plumbing first, but this
is in the electricity.
So neuromodulator means changeor modulate the nervous system.
And yes, these drugs originallywere antidepressants,
anti-anxiety, but a lot of timeswe use them in different ways
with these conditions.
So, for an example, SSRIs cansometimes be used for patients
(25:26):
that have predominant anxietyand depression features, and
actually it's because weleverage the side effects to a
certain extent.
A lot of times diarrhea can bea side effect which we can
totally leverage for aconstipated patient, right.
So something like a sertraline,for example, Zoloft we can get
by with low dose for that andthat can help calm or settle
(25:48):
down the nervous system to acertain extent.
Now, with our bigger pain people, I would actually recommend
more a SNRI for my constipatedpain patients.
So that's serotonin andnorepinephrine.
The one I love the most by faris duloxetine or Cymbalta.
It can be incredibly effectiveand treats so many different
(26:10):
things, including the pain for alot of conditions depression
and anxiety and has less of aside effect profile, especially
constipation.
Finally, tricyclics ortricyclic antidepressants
actually have the most evidenceand we use them in much lower
doses.
This is like amitriptyline ornortriptyline I would use in a
(26:31):
constipated patient because itdoesn't pass the blood-brain
barrier as much.
But that does have aconstipating side effect.
So I'd want to get the plumbingdown under control first, and
then we move into the tricyclics.
Kate Scarlata MPH, RDN (26:42):
Thanks for that.
You know, I think of people.
They hear neuromodulation (andthink).
.
.
this is used for depression.
My doctor thinks I havedepression.
What is your elevator speechabout that?
Dr. Justin Brandler (26:54):
I go back to.
It's not all in your head, butpart of it is in your nervous
system and in your brain andspinal cord and the way that we
know these work actually andthrough the class I'm able to
teach this more but we areunderstanding more about these
pathways and actually how it canhelp to control those
overactive gut to brainsignaling.
And the other thing is we canactually get by with lower doses
(27:17):
for brain gut conditions thanwe actually do for full-blown
mental health conditions.
So that's also why in some waysI'm like, hey, whatever, I'm
not even going to put anxietydepression in your chart,
because I actually don't eventhink you're anxious or
depressed, I just think yournervous system's all out of
whack and let's turn it down.
So you know, that's alsosometimes how it can be framed
(27:38):
too.
Dr. Megan Riehl (27:39):
Perfect, and people aren't going to be
usually on these for the rest oftheir life too, and therefore
having these additionalfollow-up appointments with you
to talk about their hopefullyimprovements can help them
inform future treatment.
So, from that kind oftransition, tell us what is the
(28:00):
most beneficial information thata patient can prepare to make
the most of their time with aneurogastroenterologist or
somebody like you.
Dr. Justin Brandler (28:11):
Yeah, I mean, I think first of all is
they're probably not going tosee a neurogastroenterologist,
right?
They're going to see a generalgastroenterologist, a general GI
, nurse practitioner or PA thatalso probably really care, but
they're very limited on time.
So one of the best advice I cangive you is really go in with a
good sense of what your goalsand expectations are for the
(28:34):
appointment, Because,inadvertently, what often
happens is you're suffering,right, you don't, you just want
to feel better and that's allyou want to feel.
But that's very hard for theperson on the other end of the
exam room to address withoutreally understanding what you're
looking at, what your goals are, because there's only so much
time to cover, I will say,actually a shameless plug for a
(28:57):
talk I gave a few years ago withthe IFFGD or International
Foundation for GI Disorders,which you can still find online
actually, I saw is I gave a talkcalled Living Your Best IBS
Life and in that I give you aguide of an IBS snapshot, so a
(29:17):
one-page summary of the keypoints that you can give to your
provider that you're seeing,and I will tell you if you can
summarize in a page your basichistory of your predominant
stool habits, if you're speakingthe Bristol stool chart, for
example, if you're identifyingsome of your triggers, if you're
doing those types of things, ifyou can give a one-page summary
(29:40):
, as opposed to a giant binderor a giga download of your
tracker's PDF or whatever,that's going to go so much
farther and that provider isgoing to feel so much more
empowered themselves to empoweryou with guidance as to next
steps.
So key goals and expectationsfor that visit and then
(30:00):
organizing your thoughts andhistory into a one-page summary,
if at all possible, is really,really ideal.
Kate Scarlata MPH, RDN (30:08):
Yeah, I often say like of all the
symptoms you're experiencing,try to kind of like qualify
those.
.
.
Like bloating is the mostdifficult, or pain is the most
difficult, or I'm in the toiletfor 14 hours every morning is
the most difficult.
So the physician can kind ofprioritize right and you're on
the same page.
Dr. Justin Brandler (30:27):
And quality of life too, like what of these
constellation of symptoms mostaffects your quality of life,
and that we can more precisiontarget, because from there a lot
of other things will fall inplace, because a lot of this
these aren't quantity of lifeconditions, these are quality of
life conditions, and so if wecan really focus on and pinpoint
(30:48):
the takeaway from that, thenthat can really lead to
high-yield visits.
Dr. Megan Riehl (30:53):
And Kate and I will talk more about this in
part two, but just off the topof our head again, if this is a
plumbing issue and you're tryinga bunch of different
medications over the counter andyou're just not sure and you
want some clarity, then havingthat medical provider
conversation is so important.
If you are avoiding going tothings with your family, if
(31:14):
you're at home, your avoidancebehaviors, your stress, your
anxiety, you are depressedbecause of your symptoms, that's
going to key in our physiciancolleague to make that consult
to a GI mental health provider.
Or if you're afraid to eat, youdon't know what to eat, you are
avoiding meals again it's goingto trigger that referral to a
(31:35):
GI dietician.
So it's really important againto be organized and to be open
with your physician so that theycan help guide where to go next
.
Kate Scarlata MPH, RDN (31:46):
And I would add you know, sometimes
you try a treatment, you see thedoctor and you say I feel
better, but the doctor doesn'tunderstand necessarily like how
better?
Like sometimes you try atreatment, you see the doctor
and you say I feel better, butthe doctor doesn't understand
necessarily like how better,like are you at 80% of where you
want to be, or is it you werezero and now you're 10?
Dr. Justin Brandler (32:01):
So sometimes making sure you kind
of qualify the benefits that youreceived, Actually, in my
practice now we're collectingIBS symptom severity scores so
objective scores at thebeginning, and then we see that
progress.
And it's actually so rewardingfor myself that we just talked
about this yesterday with apatient.
She went from like 330 to like20 or something.
(32:22):
It was amazing.
So rewarding for our teammembers too.
Sometimes we do mental healthscores as well to objectively
see those changes.
Sometimes we do mental healthscores as well to objectively
see those changes.
So you can work with yourprovider on how to do that,
maybe even do that beforehandfor them so that they know where
things are at.
Kate Scarlata MPH, RDN (32:38):
Well, this was amazing, and no
surprise, because you're amazing.
I couldn't have wanted a betterscenario for this episode.
.
.
you covered, from A to Z andreally understanding medications
better and the complexity ofIBS, and I love the plumbing,
electrical sort of systemalterations that are associated
(33:00):
in very simplistic terms for ourlisteners.
So thanks for your time.
Dr. Justin Brandler (33:05):
Yeah, thank you guys so much for having me.
I mean, I just like, blow up,Mind Your Gut with patients, I
mean as they're waiting to seeme.
I'm like, okay, this issomething you can read before
seeing me.
Like it's, it's promoted in theclasses, like it's just, you
guys provided such a powerfultool that I've read myself that,
as you know, that is verypatient, accessible and myth
(33:26):
busty, which is also incrediblyimportant, and a side
conversation.
So, thank you guys so much forwhat you're doing for patients
everywhere.
Dr. Megan Riehl (33:34):
Well, we look forward to ongoing collaboration
with such a rock star in themotility space and everybody out
there listening.
Please make sure that yousubscribe, like and follow The
Gut Health Podcast.
Your support means the world tous, our friends.
Kate Scarlata MPH, RDN (33:51):
Thanks everyone.
Dr. Megan Riehl (33:53):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at The Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
Popular Podcasts
The Breakfast Club
The World's Most Dangerous Morning Show, The Breakfast Club, With DJ Envy And Charlamagne Tha God!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Decisions, Decisions
Welcome to "Decisions, Decisions," the podcast where boundaries are pushed, and conversations get candid! Join your favorite hosts, Mandii B and WeezyWTF, as they dive deep into the world of non-traditional relationships and explore the often-taboo topics surrounding dating, sex, and love. Every Monday, Mandii and Weezy invite you to unlearn the outdated narratives dictated by traditional patriarchal norms. With a blend of humor, vulnerability, and authenticity, they share their personal journeys navigating their 30s, tackling the complexities of modern relationships, and engaging in thought-provoking discussions that challenge societal expectations. From groundbreaking interviews with diverse guests to relatable stories that resonate with your experiences, "Decisions, Decisions" is your go-to source for open dialogue about what it truly means to love and connect in today's world. Get ready to reshape your understanding of relationships and embrace the freedom of authentic connections—tune in and join the conversation!