What medications are used to treat bloating?

Medications for Treating Bloating

Linaclotide is the most effective medication for treating abdominal bloating, particularly in patients with IBS-C, with strong evidence showing superior efficacy compared to placebo. 1

First-line Medications for Bloating

For Bloating with Constipation

• Secretagogues are highly effective for bloating associated with constipation:
  • Linaclotide (290 μg once daily) - Superior to placebo for improving abdominal bloating in multiple trials with strong evidence of efficacy, though diarrhea is a common side effect 1
  • Lubiprostone (8 μg twice daily) - Effective for bloating in IBS-C with fewer diarrhea side effects than other secretagogues, though nausea is common 1
  • Plecanatide (3 μg or 6 μg once daily) - Effective for IBS-C symptoms including bloating 1
  • Tenapanor (50 mg twice daily) - Sodium-hydrogen exchanger-3 inhibitor shown to improve bloating in IBS-C 1

For Bloating with Diarrhea

• 5-HT3 receptor antagonists - Effective for IBS-D with bloating:

  • Ondansetron (titrated from 4 mg daily to maximum 8 mg three times daily) is a reasonable option when alosetron and ramosetron are unavailable 1
  • Constipation is the most common side effect 1

• Rifaximin - Non-absorbable antibiotic effective for IBS-D, though its effect on abdominal pain may be limited 1

• Eluxadoline - Mixed opioid receptor drug effective for IBS-D, but contraindicated in patients with sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1

Symptomatic Relief Options

• Simethicone - Antifoaming agent that can reduce bloating and abdominal discomfort by breaking up gas bubbles in the digestive tract 2, 3

  • Particularly helpful for immediate symptomatic relief
  • Shown to significantly reduce abdominal bloating compared to placebo 2

• Central neuromodulators - Effective for reducing visceral hypersensitivity that contributes to bloating sensation:

  • Tricyclic antidepressants (e.g., amitriptyline) 1
  • Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine, venlafaxine) 1
  • Pregabalin - Has shown improvements in bloating in IBS patients 1

Special Considerations

For Pregnancy-Related Bloating

• Excessive fiber and osmotic laxatives like lactulose can cause maternal bloating 1
• Polyethylene glycol-based laxatives are considered safe during pregnancy for constipation-related bloating 1

For Hepatic Impairment

• Patients with moderate to severe hepatic impairment require dose adjustments for medications like lubiprostone due to increased systemic exposure of active metabolites 4
• For severe hepatic impairment, dosage adjustments are needed for all indications 4

Non-Pharmacological Approaches

• Biofeedback therapy - Effective for bloating when a pelvic floor disorder is identified 1
• Brain-gut behavioral therapies - Including cognitive behavioral therapy and gut-directed hypnotherapy 1
• Diaphragmatic breathing - Helps with abdominophrenic dyssynergia, which can contribute to bloating 1

Treatment Algorithm

1. Identify the underlying pattern:

   • Bloating with constipation → Secretagogues (linaclotide preferred) 1
   • Bloating with diarrhea → 5-HT3 antagonists or rifaximin 1
   • Functional bloating without altered bowel habits → Simethicone and/or central neuromodulators 1, 2

2. For persistent symptoms:

   • Rule out carbohydrate enzyme deficiencies with dietary restriction and/or breath testing 1
   • Consider small intestinal bacterial overgrowth (SIBO) testing in at-risk patients 1
   • Evaluate for pelvic floor disorders with anorectal physiology testing if constipation is present 1

Common Pitfalls to Avoid

• Overuse of probiotics - Not recommended for treating abdominal bloating and distention according to AGA guidelines 1
• Failure to recognize abdominophrenic dyssynergia - This paradoxical viscerosomatic reflex can cause significant distention even with minimal gas and requires specific treatment 1
• Overlooking psychological factors - Psychological comorbidities can amplify bloating sensations and should be addressed with appropriate central neuromodulators and behavioral therapies 1