The symptoms of coeliac disease and irritable bowel syndrome can be vague and overlapping but there is plenty pharmacists can do to help raise awareness and reduce the gap between their onset and formal diagnosis
After reading this feature you should be able to:
- Support patients with coeliac disease
- Appreciate how IBS symptoms can affect a patient’s quality of life
- Explain best practice approaches to heartburn, dyspepsia and GORD.
Coeliac disease is an autoimmune condition driven by innate and adaptive immune responses to gluten, which leads to the villi in the lining of the small intestine becoming damaged.
Gluten is a complex protein found in wheat, rye, barley, wheatberries, emmer, einkorn, semolina and spelt. Coeliac disease is characterised by the presence of coeliac-specific auto-antibodies and a range of gastrointestinal symptoms of varying severity.
Gluten intolerance (or non-coeliac gluten sensitivity) describes an intolerance to gluten with symptoms similar to those of coeliac disease, but without the same antibodies and intestinal damage.
Symptoms of coeliac disease include diarrhoea with malabsorption causing high levels of fat in the stools (steatorrhoea). Others include abdominal pain, bloating and flatulence, indigestion, constipation and vomiting (mainly in children).
More general symptoms include fatigue (which may be due to deficiency of iron or vitamin B12), unexpected weight loss, inability to conceive, peripheral neuropathy, oedema of the hands, feet, arms and legs, and disorders affecting co-ordination, balance and speech (ataxia).
Although not a symptom of coeliac disease, an autoimmune reaction to gluten can lead to dermatitis herpetiformis, an itchy skin rash (most commonly on the knees, elbows and buttocks) with blisters that burst when scratched. This occurs in around 20 per cent of people with coeliac disease.
The prevalence of coeliac disease (using serological testing and inclusion of previously diagnosed patients) is about 1 per cent in the UK. However, coeliac disease is under-diagnosed, and it is estimated that for every person diagnosed, seven to eight remain undiagnosed. Prevalence has increased over the past 50 years, possibly to due to improved identification and diagnosis.
Coeliac disease affects all age groups, including older people: 70 per cent of new cases are diagnosed in people over the age of 20 years. There are two peaks of onset, one at the time of weaning with the introduction of gluten, the other in the second and third decades of life. It is more common in women than men in a ratio of up to 2:1.
While the cause of coeliac disease is not known, there is a strong genetic link with the presence of human leucocyte antigen (HLA) haplotypes (particularly HLA-DQ-2 and DQ-8). The risk of developing coeliac disease is high in those with first degree relatives with the condition. People with autoimmune conditions such as type 1 diabetes and autoimmune thyroid disease are at increased risk. There is no evidence that duration of breast-feeding or timing of introduction of gluten influence the risk of developing coeliac disease.
Diagnosis and management strategies
Pharmacy teams should consider the possibility of coeliac disease in patients presenting with any persistent unexplained gastrointestinal symptoms (e.g. acid reflux, diarrhoea, steatorrhoea, weight loss, abdominal pain, reduced appetite, bloating and constipation), irritable bowel, fatigue or lethargy, faltering growth or delayed puberty in children, persistent or recurrent mouth ulcers, patients with type 1 diabetes or autoimmune thyroid disease, or a family history of coeliac disease. Any patient with suspected coeliac disease should be referred to their doctor.
Diagnosis is usually made based on a combination of physical and clinical assessment, coeliac serological testing (e.g. immunoglobulin [Ig] A tissue transglutaminase antibody and total IgA as first-line tests) and intestinal biopsy. The patient should continue to eat a gluten-containing diet until the tests have been completed.
The only effective management for coeliac disease is long-term adherence to a gluten-free diet. This can be a difficult for patients to understand and follow. Referral to a dietitian can help to educate these patients and check for any nutritional deficiencies (e.g. iron, vitamins D and B12, and calcium).
How you can support patients
- Support patients with their prescriptions for NHS gluten-free foods (check that the prescription is endorsed ACBS). Pharmacy teams can try as many of these foods as possible so as to inform patients about taste, texture and flavour, and also available choices. Ensure as much as possible that the prescribed products of the patient’s choice are available ahead of the next prescription
- Advise patients on a healthy, nutritionally balanced gluten-free diet. Advise on gluten-free starchy alternatives such as rice, corn and potatoes
- Provide information on gluten-containing products including foods based on wheat, rye and barley (flour, bread, breakfast cereals, pastries, cakes, biscuits, batters and pies) and items that contain malt (most beers). Most patients can eat pure uncontaminated oats, but symptoms should be monitored. Many foods contain wheat, rye or barley as fillers (e.g. sausages, ready meals, soups, sauces) and foods can be contaminated with gluten during processing and packaging
- Advise patients on the importance of reading food labels. Foods with the crossed grain symbol or labelled gluten-free or very low gluten are suitable. Products containing Codex wheat starch (manufactured so that the gluten has been reduced to trace amounts) can be eaten
- Advise on the possibility of cross-contamination with gluten when cooking at home or when travelling or eating out
- Refer all patients to the Coeliac UK website (coeliac.org.uk). This contains information on gluten-free food groups, labelling, eating out and travelling, and an updated list of safe foods and drinks, recipes and the availability of gluten-free foods on prescription
- Ask how the patient is coping with the diet and reinforce the need for gluten avoidance; check for any coeliac-related symptoms (including tiredness; the possibility of nutritional deficiencies) despite self-reported adherence to a gluten-free diet. Check if weight is being maintained
- Ask about the overall quality of life and any depression or anxiety. The social impacts of sticking to a gluten-free diet can be significant (e.g. concerns about eating out, fear of exposure to gluten, embarrassment with friends, family and work colleagues, and increased costs associated with a gluten-free diet).
Irritable bowel syndrome
A recent survey for the IBS Network found that feelings of anxiety post-lockdown and less than understanding employers are contributing to misery on the part of IBS sufferers, which only results in a negative loop of stress and more symptoms. So what can pharmacy do to help?
A listening, sympathetic ear is important. The first thing to do is encourage sufferers to talk – try to find out the contributing factors, says Care brand manager Ruth Giles. “Stomach and bowel complaints were very common in the busy lifestyles associated with pre-pandemic times, with snatched, poorly balanced meals contributing significantly to how often they occur. However, the stress accompanied with the past 15 months or so has been equally as impactful.
“Some of the immediate lifestyle changes to discuss, and provide supporting materials on, include what a well-balanced diet looks like as well as the benefits of portion control, the wonderful impact exercise has on the body and stress relief, and the importance of avoiding some habitual activities such as smoking, drinking alcohol and excess consumption.”
There are plenty of NHS and third-party materials on all of these subjects and it is worthwhile having them available to share with customers presenting with symptoms (e.g. the IBS Network and NHS – IBS).
Many IBS sufferers also suffer from anxiety and depression. Understanding how the symptoms affect a patient’s life and providing support to try dietary and lifestyle modification are key to helping patients. Relaxation, leisure time and exercise help. Careful discussion with the patient to exclude more serious conditions is essential.
Various OTC medicines can help relieve symptoms and improve quality of life but check dosing and licence restrictions before making a recommendation.
IBS has three main symptoms:
- Abdominal pain
- Change in bowel habit
Pain can occur anywhere in the abdomen and may occur after eating or subside after defaecation. Constipation is common, but diarrhoea may occur, or they may alternate. Ask about the impact of symptoms on the patient’s life, work and leisure.
Advice on diet and lifestyle should be offered, but no one diet suits all patients. The NICE guideline on IBS recommends having a healthy diet with regular meals, adequate fluid intake, limiting high fibre foods such as wheat bran and limiting caffeine.
Avoiding sorbitol (found in many food products and diet drinks) can help. Food intolerances (e.g. dairy, onion, leeks, garlic, fructose) have been implicated in triggering symptoms in some patients. Probiotics can help and advice can be given to try a course for four weeks to see if that makes a difference.
Radical dietary restrictions, including the low FODMAP diet (short-chain carbohydrates that are not fully absorbed in the gut), should not be tried without a dietitian’s guidance as the patient can risk nutrient shortfalls. Patients should be advised to reduce stress as much as possible with regular exercise to contribute to overall wellbeing.
OTC therapies should be directed at the main symptom, so an antispasmodic can be tried where there is abdominal pain, loperamide for diarrhoea (OTC use in IBS is restricted to patients aged 18 years or over and when diagnosis of IBS has been made by a doctor) and a laxative where there is constipation. Patients may need to try several treatments until they find one that suits them. Check what medication the patient has tried and whether it has produced improvement.
Bulk forming laxatives (sterculia, ispaghula) may help for constipation. Stimulant or osmotic laxatives may aggravate it. Oat bran is also worth a try as it is a soluble fibre and likely to be less of an irritant than wheat bran. Remind the patient to increase fluid intake when increasing fibre.
Antispasmodics may be helpful for patients suffering from abdominal pain. Smooth muscle relaxants alverine, mebeverine and peppermint oil and the antimuscarinic hyoscine are used. Side-effects from smooth muscle relaxants are rare, but hyoscine may cause anticholinergic side-effects (e.g. dry mouth; blurred vision).
Alverine and mebeverine should not be used in children and pregnant women. Peppermint oil should not be used in children. Hyoscine can be used in adults and children over six years. There does not seem to be a difference in efficacy between OTC antispasmodics but people may respond better to one than another. Symptom improvement should occur within a few days so ask the person to return to the pharmacy after a week to monitor progress. It is worth trying another antispasmodic if the first has not worked.
Pharmacy teams should refer patients when:
- The symptoms are new (as the diagnosis needs to be confirmed)
- Persistent constipation (with concomitant weight gain, lethargy, cold intolerance, fatigue, non-specific weakness, aches and pains, which could indicate hypothyroidism)
- Persistent diarrhoea (could indicate coeliac disease, inflammatory bowel disease or gastroenteritis)
- Blood in the stool or bleeding
- Symptoms suggestive of bowel obstruction (vomiting, colicky pain, abdominal distension)
- Persistent change in bowel habit (i.e. over two weeks or longer) differing from a pattern of going to the toilet over months and years.
Children, pregnant women and patients unresponsive to lifestyle and OTC treatments should also be referred to their GP.