What medications can help alleviate bloating symptoms in a patient?

Medications for Bloating

For bloating with constipation (IBS-C), start linaclotide 290 mcg once daily, which is the most efficacious secretagogue with strong evidence for improving both bloating and abdominal pain. 1, 2

Treatment Algorithm Based on Clinical Presentation

Bloating with Constipation (IBS-C)

First-line pharmacologic therapy:

• Linaclotide 290 mcg once daily is superior to placebo for improving abdominal bloating in 4 trials with 3,061 patients and is likely the most efficacious secretagogue available. 1, 2
• Alternative secretagogues include lubiprostone 8 mcg twice daily, plecanatide, or tenapanor—all activate ion channels causing fluid efflux into the intestinal lumen. 1
• Prucalopride (a 5-HT4 agonist) is another option with a number needed to treat (NNT) of 8 for moderate-severe bloating improvement. 2

Key consideration: Diarrhea is the most common adverse effect with linaclotide, while lubiprostone more commonly causes nausea but is less likely to cause diarrhea. 1, 3

Bloating with Diarrhea (IBS-D)

Second-line pharmacologic therapy:

• Rifaximin 550 mg three times daily for 14 days improves bloating in IBS-D patients (demonstrated in 3 trials with 1,428 patients), though its effect on abdominal pain is limited. 1, 4
• Rifaximin can be repeated for symptom recurrence with no significant safety concerns. 1, 4
• 5-HT3 receptor antagonists (ondansetron 4-8 mg, titrated up to 8 mg three times daily) are the most efficacious drug class for IBS-D, though constipation is the most common side effect. 1

Functional Bloating (Without Predominant Bowel Pattern)

Central neuromodulators are the treatment of choice:

• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) or SNRIs (duloxetine, venlafaxine) show the greatest benefit in reducing visceral sensation and bloating by improving disrupted brain-gut control mechanisms. 1, 2
• These agents activate noradrenergic and serotonergic pathways, reduce perception of incoming visceral signals, and improve psychological comorbidities. 1

Medications to AVOID

Do NOT use domperidone or metoclopramide for bloating:

• The British Society of Gastroenterology and American Gastroenterological Association explicitly recommend against these prokinetics for bloating due to lack of efficacy evidence. 2
• Domperidone carries significant cardiac risks including QT prolongation, arrhythmias, and sudden cardiac death, particularly at doses >30 mg/day and in patients >60 years old. 2
• The cardiac risk is not outweighed by unproven benefits for functional bloating. 2

Probiotics are not recommended:

• Current British, European, and American guidelines for IBS do not endorse probiotics for bloating, and they may be associated with brain fogginess and lactic acidosis. 1

Peppermint oil has insufficient evidence:

• A recent placebo-controlled trial found no improvement in bloating symptoms at 6 weeks, though it has minimal adverse effects. 1

Adjunctive Therapies

When defecatory disorder is present:

• Anorectal biofeedback therapy is effective for bloating when an evacuation disorder is identified, with a 54% responder rate for bloating scores decreased by 50%. 1
• This is particularly relevant since bloating and distention are key symptoms in IBS-C and chronic constipation that overlap with dyssynergic defecation. 1

Simethicone has limited utility:

• While simethicone decreases bloating during bowel preparation for colonoscopy, its role in chronic functional bloating is less established. 5
• One small trial showed simethicone combined with Bacillus coagulans reduced bloating in IBS, but this combination is not widely recommended in major guidelines. 6

Clinical Pitfalls to Avoid

• Do not use long-term prokinetics (domperidone, metoclopramide) due to cardiac risks and lack of efficacy. 2
• Avoid indiscriminate probiotic use without evidence of benefit and potential for adverse effects. 1
• Screen for eating disorders before implementing restrictive diets like low-FODMAP, as dietary restrictions can worsen malnutrition. 1
• Recognize that bloating requires pattern recognition: constipation-predominant vs. diarrhea-predominant vs. functional bloating each require different pharmacologic approaches. 2