Low-dose amitriptyline for irritable bowel syndrome (IBS): patients’ and GPs’ views on barriers and facilitators of prescribing and uptake

Conference:

SAPC ASM 2023 - Brighton

Talk Code:

2B.2

Presenter:

Emma Teasdale

Co-authors:

Teasdale E, Everitt HA, Ford AC, Alderson SL, Hanney J, Chaddock M, Guthrie E, Wright-Hughes A, Ow P, Farrin A, Ridd M, Foy R, Cook H, Cooper D, Fernandez C, Thornton R, Herbert A, Newman S, Hartley S, Bishop FL, ATLANTIS Trial Team

Author institutions:

University of Southampton, University of Leeds, University of Bristol, University of Exeter

Problem

Irritable bowel syndrome (IBS) is a common, chronic, functional bowel disorder characterised by abdominal pain and altered bowel habit. It impacts patients’ quality of life and incurs considerable health service resource use. Many patients have ongoing troublesome symptoms. NICE Guidelines suggest considering low-dose amitriptyline if first line treatments are ineffective but currently amitriptyline is infrequently prescribed for IBS in primary care.

Approach

A qualitative interview study conducted with 42 people with IBS and 16 GPs in England to explore their views on barriers and facilitators of prescribing and uptake of low dose amitriptyline for IBS. This study was nested within the ATLANTIS trial (an NIHR HTA funded double-blind randomised placebo-controlled superiority trial of low dose amitriptyline for adults with IBS in primary care). ATLANTIS trial participants (adults 18 years and over with ongoing troublesome IBS symptoms) were recruited via GP surgeries in Wessex, West of England, West Yorkshire and were also invited to consent to be contacted about the nested qualitative study. Between April 2020 and March 2022, 140 qualitative study invitations were sent to participants who had consented to be contacted about the qualitative study. Semi-structured telephone interviews were conducted with participants at 6-months (n=42) and repeated 12-month post-randomisation (n=19). Between October 2020 and March 2022, 42 out of 55 GP practices were contacted about the qualitative study. Semi-structured telephone interviews were conducted with 16 GPs. Reflexive thematic analysis, incorporating techniques from grounded theory was used to analyse the qualitative data. Patient (6 and 12 month) and GP interview data were analysed separately. Themes from different groups of participants were then compared and contrasted with each other to identify any group-specific and overarching themes. Although analysis was primarily inductive, the common-sense model of illness perception and normalisation process theory informed the development of the interview topic guides and aided data interpretation.

Findings

Patients and GPs highlighted key factors likely to facilitate prescribing and uptake of low dose amitriptyline for IBS including addressing patient concerns about amitriptyline being an antidepressant by emphasising the low and flexible dose, potential benefits beyond IBS symptom relief and ease of treatment and addressing GP concerns around medicalising IBS by acknowledging the familiarity of amitriptyline. GPs were keen to offer more options for IBS and patients sought a cure for their symptoms.

Consequences

Patients and GPs felt the potential benefits from trying low dose amitriptyline for IBS outweighed their concerns. Depending on the trial results, GPs could offer low dose amitriptyline for IBS where appropriate. When offering low dose amitriptyline for IBS, GPs should consider addressing patient concerns about taking an antidepressant for IBS as well as highlighting the low and flexible dosage and other potential benefits of amitriptyline.

Submitted by:

Emma Teasdale

Funding acknowledgement: