What are the treatment options for Irritable Bowel Syndrome (IBS)?

Treatment Options for Irritable Bowel Syndrome (IBS)

Treatment of IBS should follow a stepwise approach starting with lifestyle modifications and dietary changes, followed by symptom-targeted pharmacological interventions, and psychological therapies for refractory cases. 1

First-Line Treatments

Lifestyle Modifications

• Regular exercise should be recommended to all IBS patients 1, 2
• Symptom monitoring using a diary may help identify possible triggers 1

Dietary Interventions

• First-line dietary advice should be offered to all patients with IBS 1, 2
• Soluble fiber (e.g., ispaghula) is effective for global symptoms and abdominal pain
  • Start at low dose (3-4 g/day) and increase gradually to avoid bloating 1
  • Insoluble fiber (e.g., wheat bran) should be avoided as it may worsen symptoms 1
• Low FODMAP diet can be considered as second-line dietary therapy
  • Implementation should be supervised by a trained dietitian 1
  • FODMAPs should be reintroduced according to tolerance 1
• Food elimination diets based on IgG antibodies are not recommended 1, 2
• Gluten-free diet is not recommended unless celiac disease is present 1, 2
• Probiotics may be effective for global symptoms and abdominal pain
  • Recommend trial for up to 12 weeks and discontinue if no improvement 1, 2

Pharmacological Treatment Based on Predominant Symptoms

For IBS with Diarrhea (IBS-D)

• Loperamide is effective for diarrhea control
  • Carefully titrate dose to avoid side effects (abdominal pain, bloating, constipation) 1, 2
• Antispasmodics may help with global symptoms and abdominal pain
  • Be aware of side effects: dry mouth, visual disturbance, dizziness 1
  • Peppermint oil can be used as an antispasmodic 2
• Second-line options:
  • 5-HT3 receptor antagonists (e.g., ondansetron 4 mg once daily, titrated up to 8 mg three times daily) 1
  • Eluxadoline (mixed opioid receptor drug) for IBS-D 1, 3
    • Contraindicated in patients with sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1
  • Rifaximin (non-absorbable antibiotic) for IBS-D 1, 4
    • Limited effect on abdominal pain 1

For IBS with Constipation (IBS-C)

• Increase dietary fiber or use ispaghula/psyllium 2
• Osmotic laxatives 5

Second-Line Treatments for All IBS Subtypes

Neuromodulators

• Tricyclic antidepressants (TCAs) are effective for global symptoms and abdominal pain 1, 2
  • Start at low dose (10 mg amitriptyline once daily)
  • Titrate slowly to maximum 30-50 mg once daily
  • Continue for at least 6 months if patient responds 2
  • Provide careful explanation of rationale and counsel about side effects 1
• Selective serotonin reuptake inhibitors (SSRIs) may be effective for global symptoms 1, 2
  • Require explanation of rationale and counseling about side effects 1

Psychological Therapies

• Consider when symptoms persist despite first-line treatments 2
• Especially recommended for symptoms refractory to pharmacological treatment for 12 months 2
• Effective options include:
  • Cognitive-behavioral therapy specific for IBS 2
  • Gut-directed hypnotherapy 2
  • Dynamic (interpersonal) psychotherapy 1
  • Stress management/relaxation techniques 1
• Most beneficial for patients who:
  • Connect symptom exacerbations to stressors
  • Have associated anxiety or depression
  • Have relatively short duration of symptoms
  • Experience waxing and waning symptoms rather than chronic pain 1

Treatment Evaluation

• Review treatment efficacy after 3 months 2
• Discontinue treatments that show no response 2

Important Considerations and Pitfalls

• Avoid extensive investigations once IBS diagnosis is established 2
• Recognize frequent comorbidity with mental health disorders 2
• Explain IBS as a disorder of gut-brain interaction 2
• Colonoscopy is not indicated unless alarm symptoms/signs are present or there's suspicion of microscopic colitis in IBS-D patients with atypical features 1
• Consider bile acid malabsorption in patients with IBS-D who have atypical features (nocturnal diarrhea, prior cholecystectomy) 1