From the Guidelines
To treat an IBS diarrhea flare, start with over-the-counter loperamide (Imodium) at 2mg after each loose stool, up to 8mg daily, and consider prescription medications like eluxadoline or rifaximin if symptoms persist. Dietary modifications are crucial during flares: follow the low-FODMAP approach by avoiding trigger foods like dairy, caffeine, alcohol, fatty foods, and high-fiber items, as supported by the AGA Clinical Practice Update on the role of diet in IBS treatment 1. Stay well-hydrated with water and electrolyte solutions while eating smaller, more frequent meals. Peppermint oil capsules (0.2-0.4ml enteric-coated) taken 2-3 times daily can help reduce intestinal spasms. Stress management techniques such as deep breathing, meditation, or gentle yoga may help, as stress often worsens IBS symptoms. Heat therapy with a heating pad on the abdomen can provide comfort.
Some key considerations for prescription medications include:
- Eluxadoline, a mixed opioid receptor drug, which is an efficacious second-line drug for IBS with diarrhea in secondary care, although its use is contraindicated in patients with prior sphincter of Oddi problems or cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1.
- Rifaximin, a nonabsorbable antibiotic, which is FDA-approved for treatment of IBS-D at a dosage of 550 mg 3 times per day for 14 days, and can be retreated up to 2 times with the same dosage regimen if symptoms recur 1.
- 5-Hydroxytryptamine 3 receptor antagonists, such as ondansetron, which can be used as an alternative, although constipation is the most common side effect 1.
It is essential to consult a healthcare provider if symptoms persist beyond 2-3 days or worsen significantly, as they can help determine the best course of treatment and provide guidance on managing IBS symptoms.
From the FDA Drug Label
1 INDICATIONS AND USAGE VIBERZI is indicated in adults for the treatment of irritable bowel syndrome with diarrhea (IBS-D).
1 INDICATIONS AND USAGE ... 1. 3 Irritable Bowel Syndrome with Diarrhea XIFAXAN is indicated for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults.
The treatment options for Irritable Bowel Syndrome (IBS) with diarrhea flare are:
- Eluxadoline (VIBERZI), a medication indicated for the treatment of IBS-D in adults 2
- Rifaximin (XIFAXAN), an antibacterial drug indicated for the treatment of IBS-D in adults 3
From the Research
Treatment Options for Irritable Bowel Syndrome (IBS) with Diarrhea Flare
- Nonpharmacological interventions:
- Dietary and lifestyle modification, which are generally used as first-line therapy 4
- Probiotics have demonstrated efficacy and safety in patients with IBS, but studies are inconsistent in strains examined, dosing, and treatment duration 4
- Psychological therapies (e.g. cognitive behavioral therapy, hypnotherapy) also may improve IBS symptoms 4
- Pharmacological interventions:
- US Food and Drug Administration-approved agents: eluxadoline, rifaximin, and alosetron 4, 5, 6
- Loperamide, smooth muscle antispasmodics, bile acid sequestrants, and antidepressants (i.e. tricyclic antidepressants, selective serotonin reuptake inhibitors) 4, 7, 8
- Eluxadoline and rifaximin have been shown to improve abdominal pain and stool consistency in patients with IBS-D 4, 5
- Alosetron improves IBS symptoms, but is approved only for women with severe IBS-D 4, 6
Specific Medications
- Rifaximin: a nonabsorbable antibiotic, has been evaluated in patients with IBS-D and shown to have mild to moderate efficacy similar to other currently available treatment options 5, 7
- Eluxadoline: a gut-targeting μ and κ opioid receptor agonist and a δ opioid receptor antagonist, has been shown to improve abdominal pain and stool consistency in patients with IBS-D 5, 6
- Loperamide: seems efficacious for diarrhea, but may have mixed results for abdominal pain 7, 6
- Antidepressants: found to be efficacious for abdominal pain, but their tolerance may be problematic and the therapeutic effect varied largely between trials 7