What are the treatment options for Irritable Bowel Syndrome (IBS) and Ulcerative Colitis (UC)?

Treatment Options for Irritable Bowel Syndrome (IBS) and Ulcerative Colitis (UC)

For IBS and UC, treatment should follow a stepwise approach starting with lifestyle modifications, followed by targeted pharmacological therapies based on predominant symptoms, and psychological interventions for refractory cases to improve morbidity, mortality, and quality of life.

First-Line Treatments for IBS

Lifestyle and Dietary Modifications

• Regular exercise should be recommended to all IBS patients 1, 2
• First-line dietary advice should be offered to all patients 1, 3
• Soluble fiber (ispaghula) is effective for global symptoms and abdominal pain, starting at low doses (3-4g/day) and gradually increasing to avoid bloating 1
• Insoluble fiber (wheat bran) should be avoided as it may worsen symptoms 1, 2
• A low FODMAP diet may be considered as second-line dietary therapy under supervision of a trained dietitian 1, 2
• Gluten-free diets are not recommended unless there is evidence of celiac disease 1, 2
• Food elimination diets based on IgG antibodies are not recommended 1, 2

Pharmacological Options for IBS

• Loperamide may be effective for diarrhea but should be carefully titrated to avoid side effects like abdominal pain, bloating, and constipation 1, 2
• Certain antispasmodics may help with global symptoms and abdominal pain but can cause dry mouth, visual disturbance, and dizziness 1, 3
• Probiotics may be effective for global symptoms and abdominal pain; recommend a 12-week trial and discontinue if no improvement 1, 3

Second-Line Treatments for IBS

Neuromodulators

• Tricyclic antidepressants (TCAs) are effective second-line drugs for global symptoms and abdominal pain 1, 2
• Start at low dose (10mg amitriptyline once daily) and titrate slowly to 30-50mg once daily 1, 3
• Selective serotonin reuptake inhibitors (SSRIs) may be effective for global symptoms 1, 2

IBS with Diarrhea-Specific Treatments

• 5-HT3 receptor antagonists are highly efficacious second-line drugs 1, 2
• Rifaximin (non-absorbable antibiotic) is effective for IBS with diarrhea, though its effect on abdominal pain is limited 1
• Eluxadoline (mixed opioid receptor drug) is efficacious but contraindicated in patients with sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 1, 4

Psychological Interventions

• Consider IBS-specific cognitive behavioral therapy or gut-directed hypnotherapy for patients with symptoms refractory to pharmacological treatment for 12 months 3, 2
• Psychological treatments are particularly beneficial for patients with overt psychiatric disorders and stress-exacerbated symptoms 1, 5

Treatment for Ulcerative Colitis

Pharmacological Management

• For active UC, treatment typically involves anti-inflammatory medications including:
  • 5-aminosalicylates (5-ASAs) for mild to moderate disease 1
  • Corticosteroids for moderate to severe flares 1
  • Immunomodulators (azathioprine, 6-mercaptopurine) for maintenance therapy 1
  • Biologics (anti-TNF agents, anti-integrins, JAK inhibitors) for moderate to severe disease or steroid-dependent cases 1

Management of Functional GI Symptoms in IBD

• Functional GI symptoms often persist in IBD patients despite inflammatory remission 1
• Tricyclic antidepressants have shown benefit for functional GI symptoms in IBD patients 1
• Avoid opiates for management of chronic abdominal pain in IBD patients 1
• Rifaximin may be beneficial in IBD patients with small intestinal bacterial overgrowth (SIBO) 1

Dietary Considerations in IBD

• Nutritional adequacy should be prioritized in IBD patients on restrictive diets 1
• Dietary instruction should be delivered by a dietitian 1
• Some IBD patients may benefit from low FODMAP diet for functional symptoms 1, 6

Important Considerations and Pitfalls

• Establish a positive diagnosis and explain the nature of IBS/UC to patients 3, 2
• Recognize IBS as a disorder of gut-brain interaction requiring explanation of the gut-brain axis to patients 3, 2
• Avoid extensive testing once diagnosis is established 3, 2
• Acknowledge that symptoms may relapse and remit over time, requiring periodic adjustment of treatment strategy 2
• Recognize the frequent comorbidity with anxiety and depression that may require specific treatment 1, 2
• Avoid opiates for chronic pain management in both IBS and IBD 1, 4
• Review treatment efficacy after 3 months and discontinue ineffective therapies 3