What is the dosage of Perinorm for irritable bowel syndrome (IBS)?

Perinorm is Not Recommended for Irritable Bowel Syndrome (IBS)

Perinorm (metoclopramide) is not recommended for the treatment of irritable bowel syndrome (IBS) according to current guidelines, as it is not included in any evidence-based treatment algorithms for IBS.

First-line Treatments for IBS

• For IBS with diarrhea, loperamide is effective at doses of 4-12 mg daily, which can be given as divided doses or a single 4 mg dose at night 1
• Certain antispasmodics may effectively treat global symptoms and abdominal pain in IBS, though they commonly cause dry mouth, visual disturbance, and dizziness 1
• Peppermint oil may effectively treat global symptoms and abdominal pain in IBS, though gastro-esophageal reflux is a common side effect 1
• For IBS with constipation, dietary fiber is recommended as first-line therapy, particularly soluble fiber like ispaghula husk at doses of 7-10.8 g daily 1, 2

Second-line Treatments for IBS

For IBS with Diarrhea:

• Tricyclic antidepressants are strongly recommended as effective second-line treatment, starting at 10 mg amitriptyline once daily and titrating to 30-50 mg once daily 1, 2
• 5-HT3 receptor antagonists like ondansetron are efficacious, starting at 4 mg once daily and titrating to maximum 8 mg three times daily 1, 2
• Eluxadoline (a mixed opioid receptor drug) is efficacious but contraindicated in patients with prior sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1
• Rifaximin (a non-absorbable antibiotic) is efficacious, though its effect on abdominal pain is limited 1

For IBS with Constipation:

• Linaclotide (a guanylate cyclase-C agonist) is strongly recommended as an efficacious second-line drug, though diarrhea is a common side effect 1, 2
• Lubiprostone (a chloride channel activator) is strongly recommended as an efficacious second-line drug with less likelihood of causing diarrhea than other secretagogues 1, 2
• Plecanatide (another guanylate cyclase-C agonist) and tenapanor (a sodium-hydrogen exchange inhibitor) are also efficacious second-line drugs 1

Why Perinorm (Metoclopramide) is Not Recommended

• Perinorm (metoclopramide) is not mentioned in any of the current guidelines for IBS management 1, 2
• Prokinetic agents like cisapride have been studied in predominantly constipated IBS patients with contradictory results, and their use cannot be recommended 1
• Current evidence supports other medications with better efficacy and safety profiles for specific IBS symptoms 3, 4

Common Pitfalls in IBS Management

• Avoid prescribing medications not supported by evidence for IBS, such as metoclopramide 2
• When prescribing tricyclic antidepressants, clearly explain they are being used for gut-brain modulation, not depression 2
• Avoid insoluble fiber (e.g., wheat bran) as it may exacerbate symptoms 2
• Be cautious with eluxadoline in patients with risk factors for sphincter of Oddi dysfunction 2
• Always start medications at low doses and titrate slowly to minimize side effects 2

Practical Approach to IBS Management

• First identify the predominant symptom (diarrhea, constipation, or pain) 5
• For diarrhea-predominant IBS, start with loperamide and consider second-line agents if symptoms persist 1
• For constipation-predominant IBS, start with soluble fiber and consider secretagogues if symptoms persist 1, 2
• For pain-predominant IBS, consider antispasmodics first, then tricyclic antidepressants 1
• Monitor for treatment response and adjust therapy accordingly 2