520 - Amitriptyline for IBS, Lung CA Screening, Where Does It Hurt?

From the Literature

1)  An Old Standby for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) affects between 5 and 10% of people globally and can cause as much disability as inflammatory bowel diseases. In the US, approximately $10 billion is spent on IBS – mostly due to increasingly costly medications recently approved to treat it. First line treatments for IBS include dietary changes and lifestyle advice, soluble fiber, antispasmodics, laxatives, and antidiarrheals. If these first-line agents fail, is there an alternative next step to the newer, more costly agents? In the UK, researchers believed amitriptyline was a good candidate to fill the bill and studied its effectiveness in a large, pragmatic, practice-based trial. This trial was started just before the COVID-19 pandemic and underwent a number of adjustments to its protocol – e.g., follow up was shortened to six months, and a planned cost-effectiveness study was indefinitely postponed.

The study was conducted in 55 general practices across the UK and participants had to have tried the first line agents without success. Patients were enrolled and randomized to amitriptyline 10 mg or placebo and were given instructions on how to titrate the medication (or corresponding placebo) up to 30 mg themselves based on symptom control. The trial was well-done, with the appropriate allocation concealment, blinding, and similar treatment in each group other than the intervention. The primary outcome was IBS symptomatology as measured by a standard scale, and the main secondary outcome was a “subjective global assessment” (i.e., the patient’s impression) that they had improved. 463 patients were ultimately enrolled, most had either IBS with diarrhea or with a mixed picture and had been symptomatic for an average of ten years. In both groups, mean age was in the late 40s and there was a 2:1 female: male predominance. There were no other important differences between groups.

Amitriptyline resulted in a 27.0-point lower IBS symptom score compared to placebo (95% confidence interval (CI) –46·9 to –7·1; p=0·0079). Subjective global assessment of improvement was also more likely in the treatment group (OR 1.78; 95% CI 1.19 to 2·66; p=0·0050). Multiple secondary outcomes also favored amitriptyline. The antidepressant side effect score was slightly higher in the amitriptyline group at three months but was no different between groups at six months. There were no differences in serious adverse events attributable to the study medication.

John’s Comments:

Medications like amitriptyline are often used off-label for indications like pain, so it is refreshing to see a primary care-based, pragmatic study that provides evidence we can use. Hopefully, we can remember diet and lifestyle measures plus simple medications like antispasmodics and amitriptyline as the first and second-line agents before reaching for the newer, more costly medications.

Reference:

• ·         Ford AC, Wright-Hughes A, Alderson SL, et al. Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment in primary care (ATLANTIS): a randomized, double-blind, placebo-controlled, phase 3 trial. The Lancet. 2023;0(0). Link

From the Literature and the American Cancer Society (ACS)

2)  Screening for Lung Cancer

Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. The principal cause of lung cancer is cigarette smoking, which accounts for approximately 80% of cases.  Early detection has been shown to be associated with reduced lung cancer mortality. 

Since 2013, both the American Cancer Society (ACS) and the US Preventive Services Task Force (USPSTF) have recommended annual lung cancer screening with low-dose computed tomography (LDCT) for specific high-risk individuals, though their criteria in terms of age-range for screening and smoking status (pack years and interval since quitting) have varied.  In March of 2021, the USPST updated their cancer screening guidance, recommending annual screening with LDCT for those between the ages of 50-80 who have at least a 20 pack-year cigarette smoking history and currently smoke or have quit within the past 15 years (B recommendation).  The ACS guideline has previously been for annual screening between the ages of 55-74 for those with a 30 pack-year cigarette smoking history and currently smoke or have quit within the past 15 years. 

The ACS recently updated their 2013 guideline and now recommends annual screening with LDCT for those aged 50-80 who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation; moderate quality evidence).  Specific details of note include:

• For individuals who formerly smoked, the number of years since quitting smoking is not included as an eligibility criterion to begin or to stop lung cancer screening.
•  Individuals with comorbid conditions that substantially limit life expectancy should not be screened.
• Before undergoing lung cancer screening, patients should:
  • Receive evidence-based smoking-cessation counseling and offered interventions if they currently smoke; and
  • Engage in a shared decision-making (SDM) discussion with a health professional that includes details about: the purpose of screening; the consensus among leading organizations on recommendations endorsing screening; the screening process and the importance of regular screening; the benefits, limitations, and potential harms of screening; and consideration of their values and preferences.  See the October 20, 2023 Take 3 for more thoughts regarding SDM. 

Mark’s Comments:

According to the American Lung Association’s 2022 "State of Lung Cancer Report", only 5.8% of eligible Americans were screened for lung cancer in 2021, and some states have screening rates as low as 1%.  The reasons for this low uptake after a decade are many and are not explained by health disparities alone.  There is no way to know yet if insurers will expand eligibility based on these new recommendations, but like other cancer screenings, perhaps an initial goal of getting all eligible patients to have at least  an initial screen based on the USPSTF recommendations would be a good place to start.  The Medicare Annual Wellness visit structure provides one helpful reminder, but for many by that time it is too late.  Let’s keep this one on our radar, and at the same time use all available resources to help those who presently smoke to stop.  As with all cancers, prevention is much preferable to treatment. 

Reference:

• Wolf A et al.  Screening for Lung Cancer: 2023 Guideline Update from the American Cancer Society.  CA Cancer J Clin 2023;1–32.  Published online 1 Nov 2023.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) It’s Okay to Tell Someone Where It Hurts

“Tell me where it hurts.” – My Mother

I was very fortunate as a young boy to hear those comforting words.  They were usually followed by, “There now, let me help make it better”, a kiss on the location of the pain, and then a hug.  And magically, it helped!  Perhaps your experience as a child was different, but for me, just having my hurts validated and not feeling alone with them seemed to help attenuate or even eliminate the pain. 

Then at some point in my “growing up,” I started rejecting attempts at comfort, pushing them away to embrace a more stoic approach to the pain of life.  “Keep a stiff upper lip,”  “big boys don’t cry,” “be a man,” and “suck it up” were the messages I received from elsewhere that drown out my mother’s voice of compassionate caring, and these became my new mantras which I carried into adulthood. 

During my professional training, the culture of medicine only reinforced and encouraged this approach to the pain and hurts of life.  As I look back, there have been many quite distressing professional circumstances that I endured but never really processed, including tragic patient outcomes, doubt about perceived medical errors, misdiagnoses, toxic interactions with colleagues, and quite regular cases of the “imposter syndrome”.  Through them all, the additional messages of “we’re the caregivers, not the cared for” and “your problems are nothing in comparison” were piled on top of my adolescent scripting.  You likely carry some variations of these scripts as well.  Quite possibly they’ve even seeped into your personal life.     

Perhaps it’s time to let go of this dysfunctional cultural and professional programming and take the courageous but also sane step of allowing more of our humanity to emerge by talking about these emotional wounds.  But how?  Acknowledging our emotional pain points can feel daunting … even scary. 

If that is the case for you, it will likely feel “safer” to start with small steps, such as some brief sharing with someone you feel affinity with.  For example, sharing “I’m having a hard time with this …” will allow you to see if they can be a “trusted other” by their willingness to listen without judgement and their ability to validate your struggles while resisting the temptation to immediately go into “fixing mode”.  Though a colleague who knows your professional world might be preferable (like your PeerRx partner), you may determine that a close non-professional friend, counselor, or therapist is more appropriate for you. 

We are in a time when the pain of the world is inescapable, including some professional hurts you are likely presently experiencing.  And mirroring our professional “scripting,” you may find yourself thinking (or even saying), “It’s no big deal” or “I don’t want to burden anyone with my problems” or “I’ve got this” and then going into the default “suck-it-up mode.”  It’s time to remind ourselves that healing can only start when we acknowledge that we hurt and where we hurt.  Having our hurts validated and not feeling alone with them can help attenuate or even eliminate the pain.  It is a really big deal.  Let’s all embrace the wisdom of my mother.  No one, including you, should hurt alone …. 

PS:  The immediate validating response to my recent MD Coaches podcast interview on avoiding isolation indicates that my story resonated with many who listened.  If you’ve not yet taken the time to listen to the podcast, I’d ask for you to reconsider. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org