From the Guidelines
The best treatment for mixed Irritable Bowel Syndrome (IBS) involves a multi-faceted approach combining dietary modifications, lifestyle changes, and medications tailored to address both diarrhea and constipation symptoms, with a strong emphasis on soluble fiber supplements, antispasmodics, and psychological therapies. When considering the management of mixed IBS, it's crucial to prioritize a holistic approach that addresses the complex interplay between gut dysfunction and psychological factors. Key components of this approach include:
- Dietary changes, such as following a low-FODMAP diet for 4-6 weeks, then systematically reintroducing foods to identify triggers, as recommended by the British Society of Gastroenterology guidelines 1
- Soluble fiber supplements like psyllium (Metamucil) at 3-4 grams daily to help regulate bowel movements, as supported by the guidelines 1
- Medication management, including antispasmodics such as dicyclomine (10-20 mg three times daily) to address abdominal pain, and loperamide (2-4 mg as needed, maximum 16 mg/day) to control diarrhea episodes, as suggested by the Rome Foundation working team report 1
- Psychological therapies, such as cognitive behavioral therapy, to address the mental health comorbidity often associated with IBS, as emphasized by the Nature Reviews Gastroenterology and Hepatology article 1 Regular physical activity, stress management techniques, and adequate sleep are also essential complementary approaches to reduce visceral hypersensitivity and improve overall symptoms. This comprehensive strategy is supported by the most recent and highest quality studies, including the 2023 review on irritable bowel syndrome and mental health comorbidity, which highlights the importance of a multidisciplinary approach to management 1.
From the Research
Treatment Options for Mixed IBS
The treatment of mixed Irritable Bowel Syndrome (IBS) involves a combination of non-pharmacological and pharmacological therapies. Some of the key treatment options include:
- Dietary modification, which is often the first line of therapy 2
- Lifestyle treatments, such as complementary alternative medications (CAM), probiotics, and peppermint oil, which can be useful adjuncts 2
- Psychotherapy, which has strong evidence to support its use in the treatment of IBS 2
- Pharmacological treatments, such as rifaximin, eluxadoline, and alosetron, which have been approved by the FDA for the treatment of IBS-D and may also be effective for mixed IBS 2, 3
Pharmacological Treatment
Some pharmacological agents that have demonstrated efficacy in IBS with diarrhea and constipation include:
- Rifaximin, which has been shown to reduce symptom severity and improve quality of life in patients with IBS-diarrhea 4, 3
- Lubiprostone, linaclotide, and plecanatide, which have demonstrated improvement of IBS with constipation in large, placebo-controlled trials 4, 3
- Peppermint oil, which has been shown to have a positive impact on some symptoms of IBS, including abdominal pain and discomfort 4, 5
- Eluxadoline, which has been approved by the FDA for the treatment of IBS-D and may also be effective for mixed IBS 2, 6
Emerging Therapies
There are several emerging therapies that may be effective for the treatment of mixed IBS, including:
- Faecal microbial transplant, which is being investigated as a potential treatment for IBS 2
- Crofelemer, which is a novel pharmacologic agent that has shown promise in the treatment of IBS-D 2
- Serotonin antagonists, which are being investigated as a potential treatment for IBS 2
- Tenapanor, a sodium/hydrogen exchanger 3 inhibitor, which appears to be a promising treatment option in the pipeline 3