From the Guidelines
Irritable Bowel Syndrome (IBS) should be diagnosed and treated using a multi-faceted approach that prioritizes dietary modifications, including soluble fibre and a low-FODMAP diet, as first-line treatments, and medications such as antispasmodics, loperamide, and tricyclic antidepressants as second-line options, according to the most recent guidelines 1.
Diagnosis
Diagnosis of IBS involves a symptom-based approach using the Rome IV criteria, which includes recurrent abdominal pain at least one day per week for the past three months, associated with changes in bowel habits. Ruling out other conditions through medical history, physical examination, and sometimes blood tests, stool studies, or colonoscopy is also necessary.
Treatment Options
Treatment involves a multi-faceted approach tailored to symptom severity, with the following options:
- Dietary modifications: + Soluble fibre, such as ispaghula, is an effective treatment for global symptoms and abdominal pain in IBS, and should be commenced at a low dose (3–4 g/day) and built up gradually to avoid bloating 2. + A diet low in fermentable oligosaccharides, disaccharides, and monosaccharides and polyols (FODMAPs) can be effective for global symptoms and abdominal pain in IBS, but its implementation should be supervised by a trained dietitian 2.
- Medications: + Antispasmodics, such as peppermint oil, can be effective for abdominal pain and global IBS symptoms 2. + Loperamide may be an effective treatment for diarrhea in IBS, but careful dose titration is necessary to avoid side effects 2. + Tricyclic antidepressants, such as amitriptyline, can be effective for abdominal pain and global IBS symptoms, and should be initiated at low doses and titrated according to symptomatic response 1.
- Psychological interventions: + Cognitive behavioral therapy and gut-directed hypnotherapy can be effective by addressing the brain-gut connection that influences symptom perception and intestinal motility 1.
- Lifestyle modifications: + Regular exercise, stress management, and adequate sleep also play important roles in managing IBS symptoms 2, 1.
Key Considerations
When treating IBS, it is essential to consider the potential benefits and risks of each treatment option, as well as the individual patient's needs and preferences. A patient-centered approach that takes into account the complex interplay between gastrointestinal and psychological factors is crucial for effective management of IBS symptoms.
From the FDA Drug Label
The Rome II criteria further categorizes IBS patients into 3 subtypes: diarrhea-predominant IBS (IBS-D), constipation-predominant IBS (IBS-C), or alternating IBS (bowel habits alternating between diarrhea and constipation). Symptoms that Cumulatively Support the Diagnosis of Irritable Bowel Syndrome: – Abnormal stool frequency (for research purposes “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week); Abnormal stool form (lumpy/hard or loose/watery stool); Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation); Passage of mucus; Bloating or feeling of abdominal distension. The efficacy of XIFAXAN for the treatment of IBS-D was established in 3 randomized, multi‑center, double-blind, placebo-controlled trials in adult patients. Adequate relief of IBS symptoms was experienced by more patients receiving XIFAXAN than those receiving placebo during the month following 2 weeks of treatment (SGA-IBS Weekly Results: 41% vs. 31%, p=0.0125; 41% vs. 32%, p=0. 0263)
The diagnosis of Irritable Bowel Syndrome (IBS) is based on the Rome II and Rome III criteria, which include symptoms such as:
- Abnormal stool frequency
- Abnormal stool form
- Abnormal stool passage
- Passage of mucus
- Bloating or feeling of abdominal distension The treatment options for IBS-D include:
- Rifaximin (XIFAXAN), which has been shown to provide adequate relief of IBS symptoms in adult patients with IBS-D 3 Key points about the treatment include:
- XIFAXAN is recommended for use in patients with IBS-D
- The primary endpoint for the trials was the proportion of patients who achieved adequate relief of IBS signs and symptoms for at least 2 of 4 weeks during the month following 14 days of treatment
From the Research
Diagnosis of Irritable Bowel Syndrome (IBS)
- The diagnosis of IBS is based on characteristic symptoms, as outlined in several symptom-based criteria for IBS, including the Rome criteria 4, 5.
- A positive diagnostic strategy, rather than a diagnostic strategy of exclusion, is suggested to improve time to initiating appropriate therapy 6.
- Serologic testing should be performed to rule out celiac disease in patients with IBS and diarrhea symptoms 6.
- Fecal calprotectin should be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease 6.
Treatment Options for IBS
- Treatment of IBS should be based on the predominant symptom, taking into account the severity of symptoms and the degree of functional impairment both physically and psychologically 4.
- Education, reassurance, dietary and lifestyle changes, and a therapeutic physician-patient relationship form the backbone of treatment for patients with mild symptoms 4.
- Pharmacologic intervention, based on the predominant symptom (diarrhea, constipation, or pain), may be used to relieve symptoms in patients with moderate symptoms 4, 7, 5, 8.
- A multidisciplinary approach, including pharmacologic treatments, psychologic treatments, and possibly a mental health or pain center involvement, may be beneficial for patients with severe or intractable symptoms 4.
- Specific treatment options for IBS include: + Chloride channel activators and guanylate cyclase activators for global IBS with constipation symptoms 6. + Rifaximin for global IBS with diarrhea symptoms 6, 8. + Gut-directed psychotherapy for global IBS symptoms 6. + A low FODMAP diet to improve global symptoms 6, 8. + Lubiprostone and linaclotide for IBS with constipation 8. + Eluxadoline for IBS with diarrhea 8.