What are the options for Irritable Bowel Syndrome (IBS) maintenance therapy?

From the Guidelines

Maintenance therapy for Irritable Bowel Syndrome (IBS) should prioritize a multimodal approach, incorporating dietary modifications, physical activity, stress management, and pharmacological treatments tailored to the predominant symptom pattern, as evidenced by the most recent guidelines 1.

Key Considerations

• Dietary modifications, such as a low FODMAP diet, should be maintained if effective during initial treatment, with successful reintroductions of FODMAPs to minimize restrictions 1.
• Regular physical activity and stress management techniques, including gut-directed hypnotherapy or cognitive behavioral therapy, complement pharmacological approaches 1.
• Pharmacological treatments should be continued if effective during the acute treatment phase, with options including:
  • For IBS with constipation (IBS-C): linaclotide, plecanatide, lubiprostone, or polyethylene glycol 1.
  • For IBS with diarrhea (IBS-D): eluxadoline or loperamide 1.
  • For pain-predominant IBS: low-dose tricyclic antidepressants or selective serotonin reuptake inhibitors 1.

Treatment Approach

• A step-wise approach should be employed, starting with first-line treatments and progressing to second-line options if necessary, with careful consideration of potential side effects and interactions 1.
• Regular follow-up every 3-6 months is recommended to assess treatment efficacy and make adjustments as needed, prioritizing patient-reported symptom responses and quality of life 1.
• The role of psychological comorbidities in IBS should be acknowledged, and treatment plans should be tailored to address these comorbidities, if present 1.

From the FDA Drug Label

Of 1,074 patients who responded to open-label XIFAXAN, 382 experienced a period of symptom inactivity or decrease that did not require repeat treatment by the time they discontinued, including patients who completed the 22 weeks after initial treatment with XIFAXAN. The median time to recurrence for patients who experienced initial response during the open-label phase with XIFAXAN was 10 weeks (range 6 to 24 weeks) Thirty-six of 308 (11.7%) of placebo patients and 56 of 328 (17.1%) of XIFAXAN-treated patients responded to the first repeat treatment and did not have recurrence of signs and symptoms through the treatment-free follow-up period (10 weeks after first repeat treatment).

Maintenance Therapy for IBS: Rifaximin may be used for maintenance therapy in patients with irritable bowel syndrome with diarrhea (IBS-D) as it has been shown to:

• Reduce the time to recurrence of symptoms
• Increase the proportion of patients who do not experience recurrence of symptoms after treatment
• Provide a treatment response in patients who have previously responded to rifaximin treatment 2 Key Points:
• The median time to recurrence of symptoms after initial treatment with rifaximin is 10 weeks
• Approximately 17% of patients treated with rifaximin do not experience recurrence of symptoms after repeat treatment, compared to 11.7% of patients treated with placebo 2

From the Research

IBS Maintenance Therapy

• The goal of IBS maintenance therapy is to manage symptoms and improve quality of life, with treatment options varying depending on the predominant symptom (constipation or diarrhea) 3, 4, 5, 6, 7.
• For constipation-predominant IBS, treatment options include fiber supplementation, polyethylene glycol, and tegaserod, a 5-HT(4) agonist, which has been shown to improve bowel frequency and stool consistency, and alleviate abdominal pain and bloating in women with C-IBS 3, 6.
• For diarrhea-predominant IBS, available therapies include loperamide, alosetron, and clonidine, with alosetron, a 5-HT(3) antagonist, being superior to placebo for reducing bowel frequency, improving stool consistency, and relieving abdominal pain in women with D-IBS 3, 4.
• Novel therapies for IBS-D, such as eluxadoline, a mixed mu-opioid agonist, and rifaximin, a broad spectrum gut-specific antibiotic, have been shown to improve abdominal pain and diarrhea symptoms, and are now FDA-approved treatments for IBS-D 4, 6.
• The American College of Gastroenterology clinical guideline for the management of IBS recommends a limited trial of a low FODMAP diet, the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms, and the use of rifaximin to treat global IBS with diarrhea symptoms 6.
• Gut-directed psychotherapy is also suggested as a treatment option for global IBS symptoms, and patient education, dietary changes, soluble fiber, and antispasmodic drugs are considered mainstays of treatment 6, 7.