Irritable bowel syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Irritable Bowel Syndrome is heterogeneous in its presentation. There are no strict guidelines for the treatment of IBS and therapy is mostly symptom-based. All IBS patients are required to adopt a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). A psychiatric referral and regular exercise are considered necessary in all IBS patients. Pharmacological therapy is adjunctive and only preferred in patients where symptoms of IBS are moderate-severe in intensity and markedly impair the quality of life. Pharmacological therapy administered to patients is based on the predominant symptom with diarrhea-predominant, constipation-predominant and pain-predominant subtypes having their own different regimens. New therapies such as herbal medicines, tight-junction modulators, mast cell stabilizers, acupuncture, and mind body therapy currently have an uncertain role in the treatment of IBS.

Medical Therapy

All subtypes of IBS

  • Preferred regimen (1): Dietary measures: Low FODMAP high fiber diet for six-eight weeks
  • Preferred regimen (2): Moderate-severe exercise: Exercise for 30-60 mins 3-5 days a week for 12 weeks
  • Preferred regimen (2): Psychiatric referral in all IBS patients

Diarrhea-predominant IBS

  • Preferred regimen (1):  Loperamide 2 mg 45 minutes prior to a meal, as needed
  • Alternative regimen (1): Ondansetron 4 mg for five weeks
  • Alternative regimen (2): Colesevelam 1.875 g q12h
  • Alternative regimen (3): Gluten free diet for 2 weeks

Constipation-predominant IBS

  • Preferred regimen (1): Psyllium half-one tbsp q24h, titrated based on response to therapy
  • Preferred regimen (2):17 g of PEG powder dissolved in 8 ounces of water q24h, may be titrated upto 34 g daily
  • Preferred regimen(3) : Lubiprostone 8 micrograms q12h for 12weeks
  • Preferred regimen (4) : Linaclotide 266 micrograms q24h for 12 weeks
  • Alternative regimen (1): Tageserod

Pain-predominant IBS:

Refractory IBS:

  • Preferred regimen (1): Rifaximin 550 mg q8h for 2 weeks

Dietary Measures

  • General dietary measures for IBS patients include:[10][11][12][13][14][15][16][17]
    • Careful dietary history
    • Caffeine and alcohol avoidance to decrease anxiety in patients
    • Legume avoidance to decrease symptoms of flatulence
    • Discouraging skipping of entire meals
    • Avoidance of large meals
    • Reduced fat intake
    • Elimination diets to help remove the most common dietary allergens[18][19][20]
    • Judicious water intake for the constipation-predominant IBS patients to prevent stool dehydration
    • Fiber supplementation
    • Scheduled timings for bowel evacuations and ensuring intake of stimulating substances such as coffee prior to the scheduled time
    • Individualized dietary recommendations for patients
    • Avoidance of gluten as gluten sensitivity may manifest in a subset of IBS patients [21][22][23][24]

Exclusion of gas-producing foods:

  • Beans, onions, celery, carrots, raisins, bananas, apricots, prunes, cabbage, onions, brussels sprouts, wheat germ, pretzels, and bagels

Physical activity 

  • Exercise plays an important role in relieving IBS symptoms by the following mechanisms :[10][40][46][47][48][49][50][51]
    • Reduction of stress
    • Protection against GI symptom aggravation
    • Alleviation of flatulence
    • Maintenance of GI function
    • Elevation of sympathetic tone, which is found to be decreased in IBS-Diarrhea patients

Psychological therapy and counseling

Pharmacological therapy

Pharmacological therapy is adjunctive and only preferred in patients where symptoms of IBS are moderate-severe and impair the quality of life.

Chloride channel activators

  • Mechanism of action:
  • Examples of chloride channel activators include:

5-hydroxytryptamine (serotonin) 3 receptor antagonists

Side effects:

5-hydroxytryptamine-4 (5-HT4) receptor agonists

  • 5HT4 receptor agonists are prokinetics or secretagogues used for constipation predominant cases of IBS.[76][77]
  • Mechanism of action:
    • Agonism of the 5-hydroxytryptamine-4 (5-HT4) receptor leads to increased motility of the colon
  • Tageserod: Partial 5-HT4 receptor agonist [78]
    • Increased cardiovascular side effects

Antispasmodic agents 

Opioids

Bile acid sequestrants

Antidepressants

Antibiotics

Probiotics

Bulk-Forming Laxatives

Other therapies 

References

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