Irritable bowel syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

IBS is heterogeneous in its presentation. There are no strict guidelines for the treatment of IBS and therapy is mostly symptom-based. All IBS patients are required to adopt a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). A psychiatric referral and regular exercise are considered necessary in all IBS patients. Pharmacological therapy is adjunctive and only preferred in patients where symptoms of IBS are moderate-severe in intensity and markedly impair the quality of life. Pharmacological therapy administered to patients is based on the predominant symptom with diarrhea-predominant, constipation-predominant and pain-predominant subtypes having their own different regimens. New therapies such as herbal medicines, tight-junction modulators, mast cell stabilizers, acupuncture, and mind body therapy currently have an uncertain role in the treatment of IBS.

Medical Therapy

All subtypes of IBS

  • Preferred regimen (1): Dietary measures: Low FODMAP high fiber diet for six-eight weeks
  • Preferred regimen (2): Moderate-severe exercise: Exercise for 30-60 mins 3-5 days a week for 12 weeks
  • Preferred regimen (2): Psychiatric referral in all IBS patients

Diarrhea-predominant IBS

  • Preferred regimen (1):  Loperamide 2 mg 45 minutes prior to a meal, as needed
  • Alternative regimen (1): Ondansetron 4 mg for five weeks
  • Alternative regimen (2): Colesevelam 1.875 g q12h
  • Alternative regimen (3): Gluten free diet for 2 weeks

Constipation-predominant IBS

  • Preferred regimen (1): Psyllium half-one tbsp q24h, titrated based on response to therapy
  • Preferred regimen (2):17 g of PEG powder dissolved in 8 ounces of water q24h, may be titrated upto 34 g daily
  • Preferred regimen(3) : Lubiprostone 8 micrograms q12h for 12weeks
  • Preferred regimen (4) : Linaclotide 266 micrograms q24h for 12 weeks
  • Alternative regimen (1): Tageserod

Pain-predominant IBS:

Refractory IBS:

  • Preferred regimen (1): Rifaximin 550 mg q8h for 2 weeks

Dietary Measures

  • General instructions:[7][8][9][10][11][12][13]
    • Careful dietary history must be taken
    • Caffeine and alcohol avoidance decreases anxiety in patients
    • Legume avoidance decreases symptoms of flatulence
    • Skipping entire meals may worsen IBS symptoms
    • Avoidance of large meals
    • Reduced fat intake
    • Elimination diets help remove the most common dietary allergens[14][15][16]
    • Judicious water intake for the constipation-predominant IBS patients to prevent stool dehydration
    • Fiber supplementation
    • Schedule times for bowel evacuations and ensure intake of stimulating substances such as coffee prior to the scheduled time
    • Individualized dietary recommendations are preferable
    • Avoidance of gluten as gluten sensitivity may manifest in a subset of IBS patients [17][18][19][20]

Exclusion of gas-producing foods:

  • Beans, onions, celery, carrots, raisins, bananas, apricots, prunes, cabbage, onions, brussels sprouts, wheat germ, pretzels, and bagels

Physical activity 

  • Exercise plays an important role in relieving IBS symptoms by the following mechanisms :[7][33][37][38][39][40][41][42]
    • Reduction of stress
    • Protection against GI symptom aggravation
    • Alleviation of flatulence
    • Maintenance of GI function
    • Elevation of sympathetic tone, which is found to be decreased in IBS-Diarrhea patients

Psychological therapy and counseling

Pharmacological therapy

Pharmacological therapy is adjunctive and only preferred in patients where symptoms of IBS are moderate-severe and impair the quality of life.

Chloride channel activators

  • Mechanism of action:
  • Examples of chloride channel activators include:

5-hydroxytryptamine (serotonin) 3 receptor antagonists

Side effects:

5-hydroxytryptamine-4 (5-HT4) receptor agonists

  • 5HT4 receptor agonists are prokinetics or secretagogues used for constipation predominant cases of IBS.[65][66]
  • Mechanism of action:
    • Agonism of the 5-hydroxytryptamine-4 (5-HT4) receptor leads to increased motility of the colon
  • Tageserod: Partial 5-HT4 receptor agonist
    • Increased cardiovascular side effects

Antispasmodic agents [67][67][68][1][6]

Opioids

Bile acid sequestrants

Antidepressants

Antibiotics

Probiotics 

Bulk-Forming Laxatives

Other therapies 

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Brandt LJ, Chey WD, Foxx-Orenstein AE, Schiller LR, Schoenfeld PS, Spiegel BM, Talley NJ, Quigley EM (2009). "An evidence-based position statement on the management of irritable bowel syndrome". Am. J. Gastroenterol. 104 Suppl 1: S1–35. doi:10.1038/ajg.2008.122. PMID 19521341.
  2. ↑ 2.0 2.1 Drossman DA, Thompson WG (1992). "The irritable bowel syndrome: review and a graduated multicomponent treatment approach". Ann. Intern. Med. 116 (12 Pt 1): 1009–16. PMID 1586090.
  3. ↑ Weinberg DS, Smalley W, Heidelbaugh JJ, Sultan S (2014). "American Gastroenterological Association Institute Guideline on the pharmacological management of irritable bowel syndrome". Gastroenterology. 147 (5): 1146–8. doi:10.1053/j.gastro.2014.09.001. PMID 25224526.
  4. ↑ Camilleri M (2012). "Pharmacology of the new treatments for lower gastrointestinal motility disorders and irritable bowel syndrome". Clin. Pharmacol. Ther. 91 (1): 44–59. doi:10.1038/clpt.2011.261. PMID 22071696.
  5. ↑ Akehurst R, Kaltenthaler E (2001). "Treatment of irritable bowel syndrome: a review of randomised controlled trials". Gut. 48 (2): 272–82. PMC 1728206. PMID 11156653.
  6. ↑ 6.0 6.1 6.2 6.3 Jailwala J, Imperiale TF, Kroenke K (2000). "Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials". Ann. Intern. Med. 133 (2): 136–47. PMID 10896640.
  7. ↑ 7.0 7.1 Kim YJ, Ban DJ (2005). "Prevalence of irritable bowel syndrome, influence of lifestyle factors and bowel habits in Korean college students". Int J Nurs Stud. 42 (3): 247–54. doi:10.1016/j.ijnurstu.2004.06.015. PMID 15708012.
  8. ↑ McKenzie YA, Alder A, Anderson W, Wills A, Goddard L, Gulia P, Jankovich E, Mutch P, Reeves LB, Singer A, Lomer MC (2012). "British Dietetic Association evidence-based guidelines for the dietary management of irritable bowel syndrome in adults". J Hum Nutr Diet. 25 (3): 260–74. doi:10.1111/j.1365-277X.2012.01242.x. PMID 22489905.
  9. ↑ Shepherd SJ, Parker FC, Muir JG, Gibson PR (2008). "Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence". Clin. Gastroenterol. Hepatol. 6 (7): 765–71. doi:10.1016/j.cgh.2008.02.058. PMID 18456565.
  10. ↑ 10.0 10.1 10.2 Ong DK, Mitchell SB, Barrett JS, Shepherd SJ, Irving PM, Biesiekierski JR, Smith S, Gibson PR, Muir JG (2010). "Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome". J. Gastroenterol. Hepatol. 25 (8): 1366–73. doi:10.1111/j.1440-1746.2010.06370.x. PMID 20659225.
  11. ↑ Austin GL, Dalton CB, Hu Y, Morris CB, Hankins J, Weinland SR, Westman EC, Yancy WS, Drossman DA (2009). "A very low-carbohydrate diet improves symptoms and quality of life in diarrhea-predominant irritable bowel syndrome". Clin. Gastroenterol. Hepatol. 7 (6): 706–708.e1. doi:10.1016/j.cgh.2009.02.023. PMC 2693479. PMID 19281859.
  12. ↑ 12.0 12.1 Rao SS, Yu S, Fedewa A (2015). "Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome". Aliment. Pharmacol. Ther. 41 (12): 1256–70. doi:10.1111/apt.13167. PMID 25903636.
  13. ↑ Atkinson W, Sheldon TA, Shaath N, Whorwell PJ (2004). "Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial". Gut. 53 (10): 1459–64. doi:10.1136/gut.2003.037697. PMC 1774223. PMID 15361495.
  14. ↑ 14.0 14.1 Lea R, Whorwell PJ (2005). "The role of food intolerance in irritable bowel syndrome". Gastroenterol. Clin. North Am. 34 (2): 247–55. doi:10.1016/j.gtc.2005.02.005. PMID 15862933.
  15. ↑ Harris LR, Roberts L (2008). "Treatments for irritable bowel syndrome: patients' attitudes and acceptability". BMC Complement Altern Med. 8: 65. doi:10.1186/1472-6882-8-65. PMC 2633319. PMID 19099570.
  16. ↑ 16.0 16.1 16.2 Heizer WD, Southern S, McGovern S (2009). "The role of diet in symptoms of irritable bowel syndrome in adults: a narrative review". J Am Diet Assoc. 109 (7): 1204–14. doi:10.1016/j.jada.2009.04.012. PMID 19559137.
  17. ↑ Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, Doecke JD, Shepherd SJ, Muir JG, Gibson PR (2011). "Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial". Am. J. Gastroenterol. 106 (3): 508–14, quiz 515. doi:10.1038/ajg.2010.487. PMID 21224837.
  18. ↑ Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR (2013). "No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates". Gastroenterology. 145 (2): 320–8.e1–3. doi:10.1053/j.gastro.2013.04.051. PMID 23648697.
  19. ↑ Vazquez-Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, O'Neill J, Carlson P, Lamsam J, Janzow D, Eckert D, Burton D, Zinsmeister AR (2013). "A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function". Gastroenterology. 144 (5): 903–911.e3. doi:10.1053/j.gastro.2013.01.049. PMC 3633663. PMID 23357715.
  20. ↑ Verdu EF, Huang X, Natividad J, Lu J, Blennerhassett PA, David CS, McKay DM, Murray JA (2008). "Gliadin-dependent neuromuscular and epithelial secretory responses in gluten-sensitive HLA-DQ8 transgenic mice". Am. J. Physiol. Gastrointest. Liver Physiol. 294 (1): G217–25. doi:10.1152/ajpgi.00225.2007. PMID 18006603.
  21. ↑ 21.0 21.1 21.2 Occhipinti K, Smith JW (2012). "Irritable bowel syndrome: a review and update". Clin Colon Rectal Surg. 25 (1): 46–52. doi:10.1055/s-0032-1301759. PMC 3348735. PMID 23449495.
  22. ↑ 22.0 22.1 Shepherd SJ, Lomer MC, Gibson PR (2013). "Short-chain carbohydrates and functional gastrointestinal disorders". Am. J. Gastroenterol. 108 (5): 707–17. doi:10.1038/ajg.2013.96. PMID 23588241.
  23. ↑ Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG (2014). "A diet low in FODMAPs reduces symptoms of irritable bowel syndrome". Gastroenterology. 146 (1): 67–75.e5. doi:10.1053/j.gastro.2013.09.046. PMID 24076059.
  24. ↑ Drisko J, Bischoff B, Hall M, McCallum R (2006). "Treating irritable bowel syndrome with a food elimination diet followed by food challenge and probiotics". J Am Coll Nutr. 25 (6): 514–22. PMID 17229899.
  25. ↑ Saberi-Firoozi M, Khademolhosseini F, Mehrabani D, Yousefi M, Salehi M, Heidary ST (2007). "Subjective lactose intolerance in apparently healthy adults in southern Iran: Is it related to irritable bowel syndrome?". Indian J Med Sci. 61 (11): 591–7. PMID 18025745.
  26. ↑ Gupta D, Ghoshal UC, Misra A, Misra A, Choudhuri G, Singh K (2007). "Lactose intolerance in patients with irritable bowel syndrome from northern India: a case-control study". J. Gastroenterol. Hepatol. 22 (12): 2261–5. doi:10.1111/j.1440-1746.2007.04986.x. PMID 17559357.
  27. ↑ Pimentel M, Chow EJ, Lin HC (2003). "Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study". Am. J. Gastroenterol. 98 (2): 412–9. doi:10.1111/j.1572-0241.2003.07234.x. PMID 12591062.
  28. ↑ Yang J, Deng Y, Chu H, Cong Y, Zhao J, Pohl D, Misselwitz B, Fried M, Dai N, Fox M (2013). "Prevalence and presentation of lactose intolerance and effects on dairy product intake in healthy subjects and patients with irritable bowel syndrome". Clin. Gastroenterol. Hepatol. 11 (3): 262–268.e1. doi:10.1016/j.cgh.2012.11.034. PMID 23246646.
  29. ↑ Zhu Y, Zheng X, Cong Y, Chu H, Fried M, Dai N, Fox M (2013). "Bloating and distention in irritable bowel syndrome: the role of gas production and visceral sensation after lactose ingestion in a population with lactase deficiency". Am. J. Gastroenterol. 108 (9): 1516–25. doi:10.1038/ajg.2013.198. PMID 23917444.
  30. ↑ Böhmer CJ, Tuynman HA (2001). "The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study". Eur J Gastroenterol Hepatol. 13 (8): 941–4. PMID 11507359.
  31. ↑ Bijkerk CJ, Muris JW, Knottnerus JA, Hoes AW, de Wit NJ (2004). "Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome". Aliment. Pharmacol. Ther. 19 (3): 245–51. PMID 14984370.
  32. ↑ 32.0 32.1 Ford AC, Talley NJ, Spiegel BM, Foxx-Orenstein AE, Schiller L, Quigley EM, Moayyedi P (2008). "Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis". BMJ. 337: a2313. PMC 2583392. PMID 19008265.
  33. ↑ 33.0 33.1 Levy RL, Linde JA, Feld KA, Crowell MD, Jeffery RW (2005). "The association of gastrointestinal symptoms with weight, diet, and exercise in weight-loss program participants". Clin. Gastroenterol. Hepatol. 3 (10): 992–6. PMID 16234045.
  34. ↑ 34.0 34.1 34.2 34.3 34.4 34.5 Talley NJ (2003). "Pharmacologic therapy for the irritable bowel syndrome". Am. J. Gastroenterol. 98 (4): 750–8. doi:10.1111/j.1572-0241.2003.07306.x. PMID 12738451.
  35. ↑ 35.0 35.1 Francis CY, Whorwell PJ (1994). "Bran and irritable bowel syndrome: time for reappraisal". Lancet. 344 (8914): 39–40. PMID 7912305.
  36. ↑ Bijkerk CJ, de Wit NJ, Muris JW, Whorwell PJ, Knottnerus JA, Hoes AW (2009). "Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial". BMJ. 339: b3154. PMC 3272664. PMID 19713235.
  37. ↑ Johannesson E, Simrén M, Strid H, Bajor A, Sadik R (2011). "Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial". Am. J. Gastroenterol. 106 (5): 915–22. doi:10.1038/ajg.2010.480. PMID 21206488.
  38. ↑ Lustyk MK, Jarrett ME, Bennett JC, Heitkemper MM (2001). "Does a physically active lifestyle improve symptoms in women with irritable bowel syndrome?". Gastroenterol Nurs. 24 (3): 129–37. PMID 11847862.
  39. ↑ Daley AJ, Grimmett C, Roberts L, Wilson S, Fatek M, Roalfe A, Singh S (2008). "The effects of exercise upon symptoms and quality of life in patients diagnosed with irritable bowel syndrome: a randomised controlled trial". Int J Sports Med. 29 (9): 778–82. doi:10.1055/s-2008-1038600. PMID 18461499.
  40. ↑ Villoria A, Serra J, Azpiroz F, Malagelada JR (2006). "Physical activity and intestinal gas clearance in patients with bloating". Am. J. Gastroenterol. 101 (11): 2552–7. doi:10.1111/j.1572-0241.2006.00873.x. PMID 17029608.
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  53. ↑ Labus J, Gupta A, Gill HK, Posserud I, Mayer M, Raeen H, Bolus R, Simren M, Naliboff BD, Mayer EA (2013). "Randomised clinical trial: symptoms of the irritable bowel syndrome are improved by a psycho-education group intervention". Aliment. Pharmacol. Ther. 37 (3): 304–15. doi:10.1111/apt.12171. PMC 3829380. PMID 23205588.
  54. ↑ Rey E, Mearin F, Alcedo J, Ciriza C, Delgado-Aros S, Freitas T, Mascarenhas M, Mínguez M, Santos J, Serra J (2017). "Optimizing the Use of Linaclotide in Patients with Constipation-Predominant Irritable Bowel Syndrome: An Expert Consensus Report". Adv Ther. 34 (3): 587–598. doi:10.1007/s12325-016-0473-8. PMC 5350198. PMID 28083815.
  55. ↑ Rao S, Lembo AJ, Shiff SJ, Lavins BJ, Currie MG, Jia XD, Shi K, MacDougall JE, Shao JZ, Eng P, Fox SM, Schneier HA, Kurtz CB, Johnston JM (2012). "A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation". Am. J. Gastroenterol. 107 (11): 1714–24, quiz p.1725. doi:10.1038/ajg.2012.255. PMC 3504311. PMID 22986440.
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  62. ↑ Garsed K, Chernova J, Hastings M, Lam C, Marciani L, Singh G, Henry A, Hall I, Whorwell P, Spiller R (2014). "A randomised trial of ondansetron for the treatment of irritable bowel syndrome with diarrhoea". Gut. 63 (10): 1617–25. doi:10.1136/gutjnl-2013-305989. PMC 4173656. PMID 24334242.
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  65. ↑ Khoshoo V, Armstead C, Landry L (2006). "Effect of a laxative with and without tegaserod in adolescents with constipation predominant irritable bowel syndrome". Aliment. Pharmacol. Ther. 23 (1): 191–6. doi:10.1111/j.1365-2036.2006.02705.x. PMID 16393297.
  66. ↑ Scott LJ, Perry CM (1999). "Tegaserod". Drugs. 58 (3): 491–6, discussion 497–8. PMID 10493276.
  67. ↑ 67.0 67.1 67.2 67.3 67.4 Ruepert L, Quartero AO, de Wit NJ, van der Heijden GJ, Rubin G, Muris JW (2011). "Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome". Cochrane Database Syst Rev (8): CD003460. doi:10.1002/14651858.CD003460.pub3. PMID 21833945.
  68. ↑ Poynard T, Regimbeau C, Benhamou Y (2001). "Meta-analysis of smooth muscle relaxants in the treatment of irritable bowel syndrome". Aliment. Pharmacol. Ther. 15 (3): 355–61. PMID 11207510.
  69. ↑ Zheng L, Lai Y, Lu W, Li B, Fan H, Yan Z, Gong C, Wan X, Wu J, Huang D, Wang Y, Mei Y, Li Z, Jiang Z, Liu X, Ye J, Yang Y, Huang H, Xiao J (2015). "Pinaverium Reduces Symptoms of Irritable Bowel Syndrome in a Multicenter, Randomized, Controlled Trial". Clin. Gastroenterol. Hepatol. 13 (7): 1285–1292.e1. doi:10.1016/j.cgh.2015.01.015. PMID 25632806.
  70. ↑ Page JG, Dirnberger GM (1981). "Treatment of the irritable bowel syndrome with Bentyl (dicyclomine hydrochloride)". J. Clin. Gastroenterol. 3 (2): 153–6. PMID 7016973.
  71. ↑ Cappello G, Spezzaferro M, Grossi L, Manzoli L, Marzio L (2007). "Peppermint oil (Mintoil) in the treatment of irritable bowel syndrome: a prospective double blind placebo-controlled randomized trial". Dig Liver Dis. 39 (6): 530–6. doi:10.1016/j.dld.2007.02.006. PMID 17420159.
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