Clinical management
How much can you trust a negative FIT?
A negative FIT can help to identify people at low risk of colorectal cancer (CRC). The NICE FIT study, a double-blinded study including almost 10,000 people referred for colonoscopy on a suspected CRC pathway, found only 0.4% with a negative FIT had CRC.
From those found to have CRC, around 1:10 have a negative FIT, so in people with persistent lower GI symptoms and a negative FIT, we should consider further investigation.
Scottish guidelines suggest a repeat FIT after 6 weeks if the first FIT is negative and the patient remains symptomatic. There is some evidence this can improve FIT sensitivity to 97%, though specificity is reduced. The British Society of Gastroenterology guidelines don’t currently recommend repeat use of FIT, citing a need for more research.
Bowel cancer screening FIT tests have a higher threshold for someone to test positive (80 to 150 µg Hb/g faeces) compared to the FIT tests we request in symptomatic patients (10 µg Hb/g faeces).
WiseGP Action
Reflect on how you manage a negative FIT test result and what safety netting advice you offer...
Do you advise patients with ongoing GI symptoms to seek further review if their FIT test is negative, when you file their result? Could you have a set text message to send to patients who test FIT negative?
If a patient attends with lower GI symptoms who has recently had a negative FIT as part of bowel cancer screening, do you request a repeat test? You should, given the threshold for a positive result is much lower in symptomatic patients- a learning point you could share with your colleagues?
Read more about the research informing this GEM here:
Amitriptyline an effective second line treatment for IBS
A trial across 55 general practices in England aimed to determine the effectiveness of amitriptyline as a second-line treatment for irritable bowel syndrome (IBS).
463 participants were randomly allocated to receive low-dose amitriptyline (10mg, with dose titration up to 30mg over 3 weeks) or placebo for 6 months. The IBS Severity Scoring System (IBS-SSS) was used to assess response to amitriptyline compared to placebo.
There was a significant improvement in the IBS-SSS after 6 months treatment with amitriptyline compared to placebo.
WiseGP Action
For people with IBS who don’t improve with first line therapies, offer low-dose amitriptyline. See a leaflet on the rationale for using amitriptyline and a dose titration document co-developed with patients here: https://ctru.leeds.ac.uk/atlantis/
Reflect on your clinical management of IBS cases and whether you discuss the brain-gut axis and explore/ support the management of psychological comorbidities.
Consider signposting patients to the IBS self-care programme- perhaps you could add this link to an automated text message at your practice?
Read more about the research informing this GEM here: https://www.sciencedirect.com/science/article/pii/S0140673623015234