From the Guidelines
The most effective management approach for diarrhea-predominant irritable bowel syndrome (IBS-D) involves a combination of dietary modifications, fiber supplementation, and medication, with alosetron being a recommended option for severe cases, as suggested by the AGA clinical practice guideline 1.
Key Management Strategies
- Dietary modifications: following a low FODMAP diet to reduce fermentable carbohydrates that can trigger symptoms
- Fiber supplementation: using soluble fiber like psyllium (starting at 3-4g daily and gradually increasing) to regulate bowel movements
- Medication management:
- Loperamide (2-4mg as needed, maximum 16mg daily) to reduce diarrhea urgency and frequency
- Antispasmodics like dicyclomine (10-20mg three to four times daily) or hyoscyamine (0.125-0.25mg every 4 hours as needed) to alleviate abdominal pain and cramping
- Alosetron (initial recommended starting dosage is 0.5 mg twice per day) for severe cases, with careful selection of patients and education about the risks and benefits 1
Additional Considerations
- Prescription medications like eluxadoline (100mg twice daily), rifaximin (550mg three times daily for 14 days), or bile acid sequestrants such as cholestyramine (4g once or twice daily) may be beneficial for patients with more severe symptoms
- Tricyclic antidepressants like amitriptyline (starting at 10mg at bedtime) can help with pain and diarrhea at low doses
- Stress management techniques, regular exercise, and adequate sleep are also important components of treatment, as they address the gut-brain interaction, reduce intestinal hypersensitivity, normalize gut motility, and modify the gut microbiome that contribute to IBS-D symptoms 1
From the FDA Drug Label
Studies in Women With Severe Diarrhea-Predominant Irritable Bowel Syndrome: Alosetron hydrochloride is indicated only for women with severe diarrhea-predominant IBS [see Indications and Usage ( 1)] . The efficacy of alosetron hydrochloride in this subset of the women studied in clinical trials is supported by prospective and retrospective analyses Prospective Analyses: Studies 3 and 4 were conducted in women with diarrhea-predominant IBS and bowel urgency on at least 50% of days at entry. Women receiving alosetron hydrochloride had significant increases over placebo (13% to 16%) in the median percentage of days with urgency control The lower gastrointestinal functions of stool consistency, stool frequency, and sense of incomplete evacuation were also evaluated by patients' daily reports.
The management of diarrhea-predominant IBS in women involves the use of alosetron hydrochloride, which has been shown to:
- Increase the median percentage of days with urgency control by 13% to 16% compared to placebo
- Improve stool consistency, with an average decrease from approximately 4 (loose) to 3.0 (formed) during 12 weeks of treatment
- Decrease stool frequency, with an average decrease from approximately 3.2 per day to 2.1 per day during 12 weeks of treatment
- Provide adequate relief of IBS pain and discomfort in a greater percentage of patients compared to placebo 2 Key points in the management of diarrhea-predominant IBS in women include:
- Alosetron hydrochloride is indicated only for women with severe diarrhea-predominant IBS
- The efficacy of alosetron hydrochloride is supported by prospective and retrospective analyses
- Alosetron hydrochloride has been shown to provide significant improvements in urgency control, stool consistency, and stool frequency compared to placebo 2
From the Research
Management of IBS-D
The management of irritable bowel syndrome with diarrhea (IBS-D) involves a combination of nonpharmacological and pharmacological interventions.
- Nonpharmacological interventions include dietary and lifestyle modifications, such as adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake 3, 4.
- Psychological therapies, such as cognitive behavioral therapy and hypnotherapy, may also improve IBS symptoms 3.
Pharmacological Interventions
Pharmacological interventions for the management of IBS-D include:
- US Food and Drug Administration-approved agents, such as eluxadoline, rifaximin, and alosetron 3, 4, 5, 6, 7.
- Other medications, such as loperamide, smooth muscle antispasmodics, bile acid sequestrants, and antidepressants (e.g. tricyclic antidepressants, selective serotonin reuptake inhibitors) 3, 4, 6, 7.
- Eluxadoline and rifaximin have been shown to improve abdominal pain and stool consistency in patients with IBS-D 3, 5.
- Rifaximin has a favorable safety profile and can be used for up to two additional retreatment courses 5.
Treatment Approach
The treatment approach for IBS-D should be personalized and consider the most troublesome symptoms, quality of life, symptom intensity, and individual patient preferences 3, 4, 7.
- A multipronged approach, including dietary modifications, psychological and pharmacological therapies, may be beneficial for patients with IBS-D 7.