The document discusses strategies for shifting physicians' treatment of irritable bowel syndrome with constipation (IBS-C) patients from traditional therapies to the new drug Zelmac. It outlines six steps or barriers physicians may face: 1) not recognizing IBS as a legitimate condition, 2) not recognizing IBS-C patients, 3) not knowing how to diagnose IBS-C, 4) treating IBS-C with diet/lifestyle changes alone, 5) using Zelmac like an antispasmodic rather than as a long-term treatment, and 6) only using Zelmac for severe patients. The summary provides probing questions and key messages to address each barrier and convince physicians to use Zel

1. Strategic Implementation:
A-to-B Shift
ZELMAC

2. Patient Categories

3. Fully understand Patient
categories… from the
doctors perspective…

4. Female Patients with
Irritable Bowel Syndrome
with constipation as
predominant symptom: C-IBS
MILD MODERATE SEVERE…

5. How do they bucket???
Mild
Moderate
Severe
1st 3rd2nd
Nothing Diet/ LSC ASP
AS ASP++ TCA/ Z
AS++ ZELMAC

6. Live with it
Positive Natural
Treater
Open and Pro-Active
To better therapies
Highly
Bothered and dissatisfied
Socially Inhibited
/ low self esteem
life highly impacted by Syndrome
The Patient Spectrum…C-IBS Females
Doctor /
Rx Avoider
123
4

7. A-to-B Shift Strategy: IBS (Doctors)
Physician does not
recognize IBS as
a legitimate condition
Physician does not recognize
the IBS-C patient
Physician diagnoses IBS-C and treats
with diet/lifestyle and
single-symptom therapies
Physician uses Zelmac first-line for all
appropriate patients
STEP # 1
STEP # 2
STEP # 3
STEP # 4
Physician uses Zelmac in some,
not all, appropriate patients
Physician does not know how to
diagnose the IBS-C patient
Physician uses Zelmac in the
same way as he uses an
antispasmodic or laxative
STEP # 5
STEP # 6

8. Physician does not recognise IBS as a legitimate
condition
Summary of Issues, Barriers, and Hurdles
• Doctor is sceptical of legitimacy of IBS as a real
medical disorder
• Does not believe that he has many IBS patients in his
practice
• Does not understand underlying cause
• Does not believe that this condition has any impact
on the patient (her quality of life and daily activities)
as well as the community at large (cost implication)
Probing Questions
• What do you believe is the cause of IBS?
• How often do you prescribe antispasmodics or
laxatives to female patients?
• How often do you regularly treat female patients for
abdominal pain and/or constipation, yet the symptoms
always return?
• How often do you see patients with A,B or C?
• How often do you see patients with a combination of
these symptoms?
Key Zelmac Messages
• IBS is a prevalent condition in the community with
prevalence ranging from 10%-20%
• IBS is a chronic condition with serotonin playing a
major role
• IBS has a significantly negative effect on a patient’s
quality of life
• It is vital that the IBS sufferer be treated so that her
quality of life can be improved
Call Objective
Highlight that IBS is a prevalent and legitimate condition in the community & has more of an
impact on quality of life versus other chronic, episodic conditions
Suggested location in the
Zelmac Global A-B A B
Key Resources
Detail aid pages:
• Pg 3 - Impact of IBS showing prevalence, costs
and consultations
• Pg 4 – IBS impact on QoL versus other chronic,
episodic conditions (asthma and migraine)
• Page 5 – IBS impact on QoL
Trials:
• Hungin et al, Franke et al, Camilleri et al , Gershon et
al

9. Physician does not recognise the IBS-C patient
Summary of Issues, Barriers, and Hurdles
• Does not think of IBS-C when the patient complains
of individual symptoms of abdominal pain, bloating or
constipation
• Does not ask the correct questions to uncover her
history and cluster of symptoms
• The patient is uncomfortable and will not volunteer all
her symptoms unless the doctor asks her
Probing Questions
• Do you have patients who you see repeatedly and are
complaining of the same symptoms?
• Do you have patients who are using antispasmodics
and laxatives frequently?
• Do you have patients who have come to see you
because the abdominal pain has been unbearable?
• Do you have patients who complain that their bloating
is so bad that they battle to fit into their clothes?
• Do you have patients, who on further questioning,
admit that their symptoms are interfering with their
quality of life?
Key Zelmac Messages
• The IBS-C patient’s predominant symptoms are
abdominal pain, bloating and constipation
• She has a longstanding history of intermittent
episodes of symptoms
• Her symptoms impact on her QoL
Call Objective Enable the doctor to recognise the IBS-C patient
Suggested location in the
Zelmac Global A-B A B
Key Resources
Detail aid pages:
• Pg 1 – IBS-C patient profile
• Pg 2 – IBS-C patient profile
Trials:
• Hungin et all, Camilleri et al , IFFGD website, Chang
et al

10. Physician does not know how to diagnose the IBS-
C patient
Summary of Issues, Barriers, and Hurdles
• GP refers “query IBS-C” patients to a specialist
• Worries that he will misdiagnose organic disease
• Only gives a diagnosis of IBS-C after ruling out all
other diseases
• Does not know what questions to ask the patient
during the diagnosis
Probing Questions
• How do you currently establish a diagnosis of IBS-C?
• Do you perform exclusion tests?
• Do you refer patients who you suspect have IBS-C?
• What would be your reasons for referring?
• On further questioning, do you find that your patients
have more symptoms and concerns than what she
originally described?
Key Zelmac Messages
• Safe, confident, positive diagnosis through identifying
the predominant symptoms of abdominal pain with
constipation (ROME II criteria); probing to establish
what other symptoms the patient has and how long
she has had the symptoms, eliminating any red flags
Call Objective
Enable the doctor to diagnosis IBS-C by using the ROME II criteria to make a positive,
symptomatic diagnosis
Suggested location in the
Zelmac Global A-B A B
Key Resources
- ROME II diagnosis folder with the list of questions
-Detail aid pages:
• Pg 1 – IBS-C patient profile
• Pg 2 – IBS-C patient profile
• Pg 6 – IBS-C impact on QoL
-Trials:
Gershon et al, Hungin et al , Camilleri et al, Chang
et al

11. Physician diagnoses IBS-C and treats with
diet/lifestyle and traditional therapies
Summary of Issues, Barriers, and Hurdles
• Doctor is resistant to change and sees no need to
change
• Feels that his current approach is risk- free
• Does not perceive the patient’s unmet needs
• Does not understand the impact on the patient’s QoL
Probing Questions
• What treatment do you recommend to your IBS-C
patients?
• Do you follow up with these patients?
• To treat the multiple symptoms, do you prescribe
combination therapy?
• Do any of your IBS-C patients ever complain that their
symptoms get worse?
• Is there any reason you have not prescribed Zelmac?
Key Zelmac Messages
• Traditional therapies do not meet the need and only
treat individual symptoms
• Traditional therapies can exacerbate other symptoms
• Traditional therapies do not address the underlying
pathophysiology of IBS-C
• Traditional therapies do not provide global
multisymptom relief
Call Objective
Convince the doctor that traditional therapies do not address the underlying pathophysiology
of IBS-C and treat individual symptoms only, often exacerbating other symptoms
Suggested location in the
Zelmac Global A-B A B
Key Resources
Detail aid pages:
• Pg 7 – traditional therapies only treat individual
symptoms
• Pg 8– what would be the ideal IBS-C treatment?
Trials:
• Camilleri et al, Brandt et al, Novick et al, Corsetti, M

12. Physician uses Zelmac in the same way as he uses
an antispasmodic or laxative
Summary of Issues, Barriers, and Hurdles
• Doctor not convinced of the role of serotonin in
mediating GI motility, stool consistency, visceral
hypersensitivity
• Doctor wants to use Zelmac as PRN treatment to
provide symptomatic relief
Probing Questions
• How long do you Rx Zelmac for?
• Why would you Rx Zelmac for 7 days only?
• How do you describe how Zelmac differs from the
traditional therapies to your patients?
• How do you explain Zelmac dosing schedule to your
patients?
Key Zelmac Messages
• Zelmac MOA is different to that of the laxatives and
antispasmodics
• Zelmac is the only drug which mimics serotonin and
thus works in 3 ways to provide multi-symptom relief
(describe the 3 ways on page 10 in your detail aid) for
IBS-C
• Zelmac MOA provides rapid and sustained clinical
efficacy throughout the treatment period
Call Objective
Convince the doctor to use Zelmac for a full month and to completely differentiate Zelmac from
the traditional therapies
Suggested location in the
Zelmac Global A-B A B
Key Resources
Detail aid pages:
• Pg 8 – What would be the ideal IBS-C treatment?
• Pg 9 – First in a new class to address the
underlying cause of IBS-C
• Pg 10 – First in a new class to address the
underlying cause of IBS-C
• Pg 11 – Mutisymptom relief
• Pg 12 - Mutisymptom relief
• Trials:
• Hungin et al, Franke et al, Camilleri et al , Gershon et
al, Muller-Lissner et al, Brandt et al.

13. Physician uses Zelmac in some, but not all
appropriate patients
Summary of Issues, Barriers, and Hurdles
• Doctor perceives Zelmac to be for the more severe
IBS-C patients
• Doctor is reserving Zelmac for a number of reasons
(you would have to probe to establish the reason):
•Efficacy
•Cost
Probing Questions
• What would stop you from using Zelmac first line in
appropriate patients?
• What have your patients said about Zelmac?
• What differentiates Zelmac from other therapies you
have used?
• Why would you reserve Zelmac ?
Key Zelmac Messages
• Zelmac is the only drug that addresses the underlying
pathophysiology of IBS-C which needs to be
addressed in all IBS-C patients
• Traditional therapies only address one symptom and
may worsen others
• Zelmac has demonstrated efficacy and safety in
clinical trials where the patients had been
experiencing symptoms for various time periods
• Zelmac, as monotherapy has an advantage in terms
of convenience and efficacy
Call Objective Convince the doctor to use Zelmac first line for all IBS-C patients and not to reserve Zelmac
Suggested location in the
Zelmac Global A-B A B
Key Resources
Detail aid pages:
• Pg 9- First in a new class to address the
underlying cause of C-IBS
• Pg 10 – First in a new class to address the
underlying cause of C-IBS
• Pg 11, 12, 13, 14 – Multisymptom relief
• Trials:
Camilleri et al , Drossman et al, Muller-Lissner et al
Brandt et al, Lacy et al , Ringel et al, Kim et al.