What medications are used to treat Irritable Bowel Syndrome (IBS) in Canada?

Medications for IBS in Canada

For IBS with constipation (IBS-C), start with polyethylene glycol or psyllium, then escalate to linaclotide 290 mcg once daily as the most effective second-line agent; for IBS with diarrhea (IBS-D), use loperamide first-line, then rifaximin or ondansetron; for abdominal pain across all subtypes, use antispasmodics initially, then low-dose tricyclic antidepressants (amitriptyline 10-30 mg at bedtime). 1, 2

IBS with Constipation (IBS-C)

First-Line Pharmacological Treatment

• Osmotic laxatives (polyethylene glycol) should be initiated first, titrating the dose according to symptoms, with abdominal pain being the most common side effect 1, 2
• Soluble fiber (psyllium/ispaghula) at 3-4 g/day is effective for global symptoms and abdominal pain, but must be increased gradually to avoid bloating and gas 1, 3, 2
• Avoid insoluble fiber (wheat bran) as it consistently worsens IBS-C symptoms 1, 3

Second-Line Pharmacological Treatment

• Linaclotide 290 mcg once daily is the most effective secretagogue available for IBS-C and should be the preferred second-line agent when first-line therapies fail, with studies conducted in Canada showing 30% reduction in abdominal pain and increased complete spontaneous bowel movements 1, 2
• Lubiprostone 8 mcg twice daily (FDA-approved for IBS-C in women ≥18 years) is an alternative if linaclotide is not tolerated, with less likelihood of causing diarrhea than other secretagogues, though nausea is a frequent side effect 1, 3, 4, 2
• Plecanatide 3 mg once daily is another guanylate cyclase-C agonist option, though diarrhea is a common side effect 1, 3
• Tenapanor 50 mg twice daily is effective for IBS-C but availability in Canada may be limited 1

For Abdominal Pain in IBS-C

• Antispasmodics with anticholinergic properties (dicyclomine) can be effective for abdominal pain and global symptoms, though dry mouth, visual disturbance, and dizziness are common side effects 1, 3, 5
• Peppermint oil is effective for abdominal pain with gastroesophageal reflux being the main side effect 1, 3, 5

IBS with Diarrhea (IBS-D)

First-Line Pharmacological Treatment

• Loperamide 2-4 mg up to four times daily is effective for controlling stool frequency, urgency, and fecal soiling, though it has limited effect on abdominal pain 1, 3, 2
• Titrate loperamide carefully to avoid constipation, abdominal pain, and bloating 1, 2

Second-Line Pharmacological Treatment

• Rifaximin 550 mg three times daily for 14 days is effective for IBS-D, though its effect on abdominal pain is limited 1, 3, 6, 2
• 5-HT3 receptor antagonists (ondansetron) starting at 4 mg once daily and titrating to maximum 8 mg three times daily are highly efficacious for IBS-D 1, 3, 2
• Eluxadoline (μ-opioid and κ-opioid receptor agonist) is effective for IBS-D but is contraindicated in patients with prior sphincter of Oddi problems, cholecystectomy, alcohol dependence, pancreatitis, or severe liver impairment 3, 2

Abdominal Pain Management Across All IBS Subtypes

First-Line for Pain

• Antispasmodics (cimetropium, dicyclomine, hyoscine) are effective for abdominal pain, particularly when symptoms are exacerbated by meals 1, 3, 5
• Peppermint oil is effective for abdominal pain and global symptoms 1, 3, 2, 5

Second-Line for Refractory Pain

• Tricyclic antidepressants (amitriptyline) starting at 10 mg once daily at bedtime, titrated slowly to 30-50 mg daily, are the most effective treatment for refractory abdominal pain and global symptoms across all IBS subtypes 1, 3, 2, 5
• TCAs should be continued for at least 6 months if the patient reports symptomatic response 1, 3
• In IBS-C, use TCAs cautiously as they may worsen constipation; ensure adequate laxative therapy is in place 3
• Selective serotonin reuptake inhibitors (SSRIs) may be effective as second-line neuromodulators for global symptoms when TCAs are not tolerated, though evidence quality is lower than for TCAs 1, 3, 5

IBS with Mixed Symptoms (IBS-M)

• Tricyclic antidepressants (amitriptyline 10-30 mg once daily) are the most effective first-line pharmacological treatment for mixed IBS 3
• Treat predominant symptoms with symptom-specific agents: loperamide for diarrhea episodes, osmotic laxatives for constipation episodes 3
• Antispasmodics are effective for reducing abdominal pain in mixed IBS 3

Additional Therapies

Probiotics

• A 12-week trial of probiotics may be effective for global symptoms and abdominal pain, though no specific strain can be recommended; discontinue if no improvement occurs 1, 2

Psychological Therapies for Refractory Symptoms

• Cognitive-behavioral therapy specific for IBS and gut-directed hypnotherapy are effective when symptoms persist despite 12 months of pharmacological treatment 1, 3, 2

Critical Pitfalls to Avoid

• Do not use loperamide as primary treatment for abdominal pain as it has limited effect on pain 1, 3
• Avoid insoluble fiber (wheat bran) as it worsens symptoms 1, 3
• Do not recommend gluten-free diets unless celiac disease is confirmed 1, 3, 2
• Do not use IgG antibody-based food elimination diets as they lack evidence 3, 2
• When prescribing TCAs or SSRIs, clearly explain they are being used for gut-brain modulation, not depression 1, 3
• Lubiprostone should be taken with food and water to reduce nausea; patients should be aware of possible syncope and hypotension, particularly within the first hour after dosing 4
• Rifaximin is not suitable for treating systemic bacterial infections due to limited systemic absorption 6
• Manage patient expectations: complete symptom resolution is often not achievable; the goal is symptom relief and improved quality of life 1