What medication is indicated for bloating?

Medications for Abdominal Bloating

For abdominal bloating, secretagogues like linaclotide are the most effective medications, particularly when bloating is associated with constipation. 1, 2

First-Line Treatments

Based on Underlying Cause:

1. For bloating with constipation:

   • Secretagogues (most effective option):
     • Linaclotide (290 μg once daily) - most efficacious for bloating in IBS-C 1, 3
     • Lubiprostone (8 μg twice daily) - less likely to cause diarrhea than other secretagogues 1, 4
     • Plecanatide (3-6 μg once daily) 1
     • Tenapanor 1

2. For bloating with gas:

   • Simethicone (180 mg after meals and at bedtime) 2, 5
   • Non-absorbable antibiotics:
     • Rifaximin (550 mg three times daily for 14 days) - reduces hydrogen production and flatus episodes 2, 6

3. For visceral hypersensitivity causing bloating:

   • Central neuromodulators:
     • Tricyclic antidepressants (e.g., amitriptyline 10-50 mg at bedtime) 1, 2
     • Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine) 1
     • Pregabalin - shown to improve bloating in IBS patients 1, 2

Treatment Algorithm

1. Step 1: Identify predominant symptom pattern

   • Bloating with constipation
   • Bloating with diarrhea
   • Bloating with normal bowel movements
   • Bloating with excessive gas

2. Step 2: Initial treatment based on pattern

   • For bloating with constipation:

     • Start with linaclotide 290 μg once daily (take on empty stomach) 1, 3
     • Alternative: lubiprostone 8 μg twice daily if diarrhea is a concern 1, 4

   • For bloating with normal bowel movements or excessive gas:

     • Trial of simethicone 180 mg after meals 2, 5
     • Consider rifaximin if small intestinal bacterial overgrowth is suspected 2, 6

   • For bloating with visceral hypersensitivity:

     • Start amitriptyline 10 mg at bedtime, titrate up to 25-50 mg as needed 1, 2
     • Avoid if constipation is a major feature

Efficacy and Evidence

• Linaclotide has demonstrated superior efficacy for bloating in multiple RCTs with 3061 patients (RR 0.82; 95% CI 0.78 to 0.87) 1
• Lubiprostone improved bloating in 2 RCTs with 452 patients 1, 4
• Rifaximin has been shown to significantly reduce hydrogen production and excessive flatus episodes 6
• Central neuromodulators like amitriptyline and pregabalin improve bloating by reducing visceral hypersensitivity 1, 2

Important Considerations

• Side effects:

  • Linaclotide: diarrhea is common 1, 3
  • Lubiprostone: nausea is common 1, 4
  • Tricyclic antidepressants: dry mouth, constipation, sedation 1, 2
  • Lactulose: can worsen bloating and flatulence 1

• Cautions:

  • Avoid magnesium oxide in patients with renal insufficiency 1
  • Start central neuromodulators at low doses and titrate slowly 2
  • Avoid tricyclic antidepressants if constipation is a major feature 1

• Complementary approaches:

  • Consider 2-week trial of dietary restriction to identify food intolerances 1, 2
  • Brain-gut behavioral therapies like cognitive behavioral therapy or hypnotherapy may help 1

The British Society of Gastroenterology and American Gastroenterological Association guidelines support the use of secretagogues as the most effective medications for bloating, particularly when associated with constipation 1. For patients with normal bowel habits or excessive gas, simethicone and rifaximin offer targeted relief 2, 5, 6.