What treatment options are available for patients with medication-resistant irritable bowel syndrome (IBS)?

From the Guidelines

For patients with medication-resistant irritable bowel syndrome (IBS), a multidisciplinary approach incorporating neuromodulators, dietary changes, and psychological therapies is recommended to improve symptoms and quality of life. The most recent and highest quality study 1 suggests that a patient-centered approach, considering the gut-brain axis and mental health comorbidity, is essential in managing IBS. Key treatment options include:

• Neuromodulators such as low-dose tricyclic antidepressants (amitriptyline 10-50 mg at bedtime) or selective serotonin reuptake inhibitors, which can help reduce abdominal pain and global IBS symptoms 1
• Dietary changes, including a low FODMAP diet, which can help identify trigger foods and reduce symptoms 1
• Psychological therapies, such as cognitive behavioral therapy (CBT) and gut-directed hypnotherapy, which can address the brain-gut connection and reduce stress-triggered symptoms 1
• Mind-body interventions, including meditation, yoga, and gut-directed relaxation techniques, which can reduce stress and improve symptoms 1 It is essential to note that each patient's treatment plan should be individualized, taking into account their specific symptoms, medical history, and lifestyle. A collaborative approach between healthcare providers, including gastroenterologists, dietitians, and mental health professionals, is crucial in providing comprehensive care for patients with medication-resistant IBS. By prioritizing a multidisciplinary approach and incorporating the latest evidence-based treatments, healthcare providers can improve outcomes and enhance the quality of life for patients with medication-resistant IBS.

From the FDA Drug Label

Table 1 Adverse Reactions Reported in ≥1% of Patients with Irritable Bowel Syndrome and More Frequently on Alosetron Hydrochloride 1 mg Twice Daily Than Placebo Alosetron Hydrochloride Body System | Placebo | 1 mg twice daily Adverse Reaction | (n = 2,363) | (n = 8,328) Gastrointestinal | | Constipation | 6% | 29% Abdominal discomfort and pain | 4% | 7% Nausea | 5% | 6% Gastrointestinal discomfort and pain | 3% | 5% Abdominal distention | 1% | 2% Regurgitation and reflux | 2% | 2% Hemorrhoids | 1% | 2%

The treatment option available for patients with medication-resistant irritable bowel syndrome (IBS) is alosetron hydrochloride.

• Key points:
  • Alosetron hydrochloride is used to treat severe diarrhea-predominant IBS in women.
  • Common adverse reactions include constipation, abdominal discomfort and pain, nausea, and gastrointestinal discomfort and pain.
  • The incidence of constipation is dose-related and was reported in approximately 29% of patients with IBS treated with alosetron hydrochloride 1 mg twice daily.
  • Serious complications of constipation have been reported in clinical studies and in postmarketing experience. 2

From the Research

Treatment Options for Medication-Resistant Irritable Bowel Syndrome (IBS)

• The American College of Gastroenterology clinical guideline for the management of IBS suggests a positive diagnostic strategy and recommends a limited trial of a low FODMAP diet to improve global symptoms 3.
• For patients with IBS and diarrhea symptoms, the guideline recommends the use of rifaximin, while for those with constipation symptoms, it recommends the use of chloride channel activators and guanylate cyclase activators 3.
• Gut-directed psychotherapy is also suggested as a treatment option for global IBS symptoms 3.

Role of Antidepressants in IBS Treatment

• A systematic review of antidepressant therapies for IBS found that tricyclic antidepressants were more effective than selective serotonin reuptake inhibitors in improving global symptom relief in IBS 4.
• Another study compared tianeptine with amitriptyline for the treatment of IBS with diarrhea and found that tianeptine was not inferior to amitriptyline in terms of efficacy and tolerability 5.

Improving Medication Adherence in IBS

• A systematic review of interventions to enhance medication adherence in inflammatory bowel disease found that multicomponent interventions demonstrated the greatest success in promoting medication adherence 6.
• The review suggested that future research should focus on a multidisciplinary approach to design multicomponent interventions to optimize treatment adherence and enhance long-term clinical outcomes 6.

Diagnosis and Treatment of IBS

• A review of the diagnosis and treatment of IBS highlighted the importance of a symptom-based diagnosis and the need for additional history, physical examination, and screening tests to exclude organic disease 7.
• The review also emphasized the need for individualized treatment approaches for patients who do not respond to first-line treatments, including testing for specific functional disorders and targeted therapies 7.