From the Guidelines
Treatment of irritable bowel syndrome with diarrhea (IBS-D) should prioritize a step-up approach, starting with lifestyle modifications, including a low-FODMAP diet and stress management, before progressing to medications such as loperamide or antispasmodics. This approach is supported by the most recent and highest quality study, which suggests that lifestyle modifications can significantly reduce symptoms 1.
Lifestyle Modifications
- Dietary changes, including a low-FODMAP diet, can help identify trigger foods and reduce symptoms
- Stress management techniques, such as cognitive behavioral therapy, mindfulness, and regular exercise, can also reduce symptoms
- A stepwise approach to rule-out ongoing inflammatory activity should be followed in patients with persistent GI symptoms, as recommended by the AGA clinical practice update 1
Medications
- Loperamide (Imodium) 2-4mg as needed can help control acute diarrhea episodes, although its effectiveness in reducing global symptoms is limited 1
- Antispasmodics, such as dicyclomine (Bentyl) 10-20mg three times daily, can reduce abdominal pain and cramping, with a significant benefit in reducing persistent global symptoms or abdominal pain 1
- For patients with more severe symptoms, prescription medications, such as eluxadoline (Viberzi) or rifaximin (Xifaxan), may be considered, although their use should be individualized based on symptom severity
Individualized Treatment
- Treatment should be tailored to the individual patient's symptom severity and response to therapy
- A low FODMAP diet may be offered for management of functional GI symptoms, with careful attention to nutritional adequacy 1
- Psychological therapies, such as cognitive behavioral therapy, hypnotherapy, or mindfulness therapy, should be considered in patients with functional symptoms 1
From the FDA Drug Label
XIFAXAN is indicated for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults. The recommended dose of XIFAXAN is one 550 mg tablet taken orally three times a day for 14 days. VIBERZI is indicated in adults for the treatment of irritable bowel syndrome with diarrhea (IBS-D).
Treatment of IBS-D can be done using:
- Rifaximin (XIFAXAN): 550 mg orally three times a day for 14 days 2
- Eluxadoline (VIBERZI): dosage not specified in the provided label, but it is indicated for the treatment of IBS-D in adults 3
From the Research
Treatment Options for IBS-D
- Dietary and lifestyle modifications, such as adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake, may lead to symptom improvement 4
- Over-the-counter medications like loperamide are frequently recommended and may improve stool frequency and rectal urgency, but have mixed results for abdominal pain 4
- Several off-label prescription medications, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics, are useful in IBS-D management 4
- Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin 4, 5, 6
Eluxadoline Efficacy
- Eluxadoline has been shown to be effective in treating IBS-D symptoms, including abdominal pain and diarrhea, in patients with an intact gallbladder reporting inadequate relief with prior loperamide use 7, 8
- A significantly greater proportion of eluxadoline patients achieved the primary composite responder endpoint compared to placebo, with improvements in stool consistency and worst abdominal pain 7
- Eluxadoline appears safe and effective for treating IBS-D symptoms, with comparable efficacy and safety irrespective of the use of loperamide as a rescue medication during eluxadoline treatment 7, 8
Clinical Practice
- Eluxadoline and rifaximin can be utilized sequentially, taking into consideration patient symptoms and severity, prior medical history, mode of action, cost, availability, managed care coverage, and adverse event profiles 5
- Clinicians should weigh the benefits and risks of pharmacologic interventions during treatment selection, and consider the use of eluxadoline and other approved medications in the management of IBS-D 4, 5