Can a patient stay on Vibrezi (eluxadoline) after cholecystectomy (gallbladder removal)?

Eluxadoline (Viberzi) is Contraindicated After Cholecystectomy

Patients who have had a cholecystectomy (gallbladder removal) should NOT take Viberzi (eluxadoline) due to increased risk of serious adverse reactions including pancreatitis and sphincter of Oddi spasm. 1

Contraindication Evidence

• Eluxadoline is explicitly contraindicated in patients without a gallbladder according to the FDA drug label, as these patients are at increased risk of developing serious adverse reactions including pancreatitis and/or sphincter of Oddi spasm 1
• The British Society of Gastroenterology guidelines on IBS management clearly state that eluxadoline is contraindicated in patients with prior cholecystectomy 2
• Multiple case reports have documented serious pancreatitis in post-cholecystectomy patients taking eluxadoline, even at the reduced dose of 75 mg 3, 4

Mechanism of Risk

• The absence of a gallbladder prevents cholecystokinin-mediated relaxation of the sphincter of Oddi, contributing to increased spasms when taking eluxadoline 4
• Most reported cases of serious pancreatitis occurred within a week of starting treatment with eluxadoline, and some developed symptoms after just one to two doses 1
• Fatal cases have been reported in patients without a gallbladder who were prescribed eluxadoline 1

Alternative Treatment Options for IBS-D After Cholecystectomy

For patients with IBS-D who have had a cholecystectomy, alternative treatment options include:

• Loperamide may be effective for diarrhea in IBS, though careful dose titration is needed to avoid side effects like constipation, bloating, and nausea 2
• 5-HT3 receptor antagonists (such as ondansetron) are efficacious second-line drugs for IBS-D, with ondansetron typically titrated from 4 mg once daily to a maximum of 8 mg three times daily 2
• Rifaximin, a non-absorbable antibiotic, is an efficacious second-line option for IBS-D, though its effect on abdominal pain may be limited 2
• Tricyclic antidepressants used as gut-brain neuromodulators are effective second-line treatments for global symptoms and abdominal pain in IBS, starting at low doses (e.g., 10 mg amitriptyline once daily) 2

Post-Cholecystectomy Diarrhea Management

• For patients experiencing diarrhea after cholecystectomy (which may be due to bile acid diarrhea rather than IBS-D), bile acid sequestrants like cholestyramine may be effective 2
• In patients with post-cholecystectomy bile acid diarrhea, cholestyramine (2-12 g/day) has shown effectiveness, with some patients able to maintain symptom control using intermittent, on-demand dosing 2
• For those unable to tolerate bile acid sequestrants, alternative anti-diarrheal agents should be considered for long-term symptomatic therapy 2

Important Clinical Considerations

• Always assess for bile acid diarrhea in post-cholecystectomy patients with diarrhea before assuming IBS-D as the diagnosis 2
• Recurrent common bile duct stones occur in approximately 5.9-11.3% of patients after cholecystectomy and should be ruled out as a cause of symptoms 5
• Monitor for any signs of biliary complications in post-cholecystectomy patients with persistent symptoms, as these may require specific treatment approaches 2
• When selecting alternative treatments for IBS-D in post-cholecystectomy patients, consider individual factors such as symptom severity, comorbidities, and previous treatment responses 2