Management options for IBS

Successful IBS management
relies on a strong patient and
healthcare provider relationship. 

Clinical care pathway

Management strategies for IBS may include lifestyle and dietary changes, over-the-counter medications, and prescription medications.1,2 Successful management of IBS involves an individualized treatment approach by working closely with patients over time to better understand the patients’ characteristic symptoms and needs, provide education, and identify the most suitable treatment plan together.1-3 Below are some key steps that may help guide effective long-term management of IBS. 

Patient Education AND Shared Decision Making

The overall goal should be to develop a mutually agreeable management plan with realistic expectations.4 Encourage patients to lead discussions through patient-centered interviewing regarding their experiences, worries, preferences, and expectations. 

You can provide education regarding the causes and natural history of IBS.3 Shared decision making is distinct from and goes beyond patient education or the provision of informed consent in that it is bidirectional communication wherein the patient gains insight into treatment options and the clinician gains an appreciation for what matters to the patient. This can be reassuring to the patient and help improve outcomes.4-8 

Be sure to inform patients regarding common points of concern:

  • Symptoms are not life-threatening; focusing on creating a treatment plan to alleviate symptoms can provide optimism for patients that IBS can be successfully managed3,9
  • There is no increased risk of cancer in patients with IBS; careful explanations of the nature of the disease will help reduce fears3
  • There is no direct “cure” for IBS; reassurance and explanation of the disease course are vital3

Lifestyle AND diet

Encourage your patients to practice healthy habits, such as:3

  • Regular exercise, e.g., a 20-minute walk each day3
  • Good sleep hygiene, e.g., having a period of time for relaxation before going to bed, avoiding food or drinks with caffeine for at least 4 hours before bedtime, and refraining from viewing a TV screen before sleeping10
  • Healthy eating behavior, e.g., taking time over meals, sitting down to eat, and eating regularly11

Specialized diets, such as a low-FODMAP diet, may be an appropriate recommendation based on the patient’s history and symptoms.12-14 Consider if symptoms appear linked to specific “triggers,” and if so consider if reducing or avoiding these is appropriate. Common triggers include:15,16

Caffeine

Artificial sweeteners (e.g., diet candies and chewing gum)

Spicy foods

Legumes (e.g., beans and lentils)

Dairy products

High-fiber foods

Psychosocial considerations

Anxiety, depression, and other psychological disorders may be present in some patients with IBS.17 Therefore, it is important to assess patient history and observe whether psychological issues are present.18,19 Anxiety in patients with IBS may also be symptom-related and stress reduction may be beneficial.20 The following relaxation techniques may be worth discussing with your patients based on their symptom history:20

  • Meditation
  • Deep breathing
  • Yoga

The pathophysiology of IBS is multifactorial, and personalized approaches based on IBS severity, most bothersome symptom(s), and factors that drive symptom experience are critical to effective care. Gut-directed psychotherapies (GDPs), which as a class include cognitive-behavior therapy (CBT) and gut-directed hypnotherapy (GDH), improve IBS symptom severity by targeting the cognitive and affective factors known to drive symptom experience. Cognitive and affective states are driven by the emotional centers of the brain and determine how input from the gut is perceived, interpreted, and regulated.22

Examples of cognitive-affective factors that negatively impact IBS are fear of symptoms, pain catastrophizing, attentional bias/hypervigilance, somatization, and stress sensitivity. GDPs are less effective in patients with comorbid mental health conditions; these patients should be referred to non-GI mental health professionals for care.22

Pharmacological management

Pharmacological interventions are often important and potentially necessary along with dietary and lifestyle changes.3 Treatments should be tailored to the individual patient and take into account the severity of the disease (mild, moderate, or severe), which is typically assessed subjectively in practice based on frequency of symptoms and impact of symptoms on patients’ daily lives.21 Over-the-counter medications that target specific symptoms, such as laxatives, antidiarrheals, or antispasmodics, may be appropriate for patients with mild IBS symptoms, and can often be used on an as-needed basis.3

Other pharmacological options for treatment of IBS can be considered depending on the patient’s history and symptoms.3

Reassessment

IBS management is an ongoing process. It is important to work with patients by providing information on lifestyle, diet, and pharmacological options to ultimately improve their quality of life.21 A regular follow-up should be conducted to assess patient progress, depending on the patient’s personal and symptom history.21 If patient symptoms are not improving, additional or alternative treatment options should be considered.21

ACG Recommendations for Management of IBS22

Class Medication Use/Indication ACG 2021 Guideline Recommendations
PRESCRIPTION (RX) MEDICATIONS FOR IBS-C
Secretagogues - GC-C agonists linaclotide, plecanatide IBS-C in adults Recommended (strong/high evidence)
Secretagogues - Cl channel activators lubiprostone IBS-C in adult women Recommended (strong/moderate evidence)
5-HT4 agonists tegaserod IBS-C in adult women <65 years of age Suggested in women <65 years with ≤1 cardiovascular risk factor who have not responded to secretaogues (conditional/low)
PRESCRIPTION (RX) MEDICATIONS FOR IBS
Neuromodulators tricyclic antidepressants (desipramine, amitriptyline, etc.) Not approved for IBS Recommended (strong/moderate evidence)
SSRIs, SNRIs Not approved for IBS N/A
Antispasmodics dicyclomine IBS in adults Not recommended (conditional/low evidence)
hyoscyamine Not approved for IBS
OVER-THE-COUNTER (OTC) PRODUCTS
Soluble fiber laxatives psyllium Not approved for IBS Suggested (strong/moderate evidence)
Herbal remedy peppermint Not approved for IBS Suggested (conditional/low evidence)
Osmotic laxatives polyethylene glycol Not approved for IBS Not suggested (conditional/low evidence)
Probiotics Lactobacillus spp., Bifidobacterium spp., etc. Not approved for IBS Not suggested (conditional/very low evidence)
Stool softners docusate Not approved for IBS N/A

QUALITY OF EVIDENCE is expressed as23

  • High: Estimate of effect is unlikely to change with new data
  • Moderate: Likely to have an important impact on our confidence in the estimate of effect and may change the estimate
  • Low: Likely to have an important impact on our confidence in the estimate of effect and may change the estimate
  • Very low: Any estimate of effect is very uncertain

STRENGTH OF RECOMMENDATION is classified as22

  • Strong: Most patients should receive the recommended course of action
  • Conditional: Many patients will have this recommended course of action, but different choices may be appropriate for some patients

Clinical Practice Guidelines were published in 2021 by the American College of Gastroenterology (ACG). The recommendations were based on the GRADE methodology. This information is provided as a reference tool only and is not a substitute for clinical judgment. Each healthcare provider is solely responsible for any decisions made or actions taken in reliance of this information.

Class Medication Use/Indication ACG 2021 Guideline Recommendations
PRESCRIPTION (RX) MEDICATIONS FOR IBS-D
Non-absorbable Antibiotics rifaxamin IBS-D in adults Recommended (strong/moderate evidence)
Mixed opioid agonist/antagonist eluxadoline IBS-D in adults Suggested (conditional/moderate evidence)
5-HT3 agonist alosetron Severe IBS-D in women who do not respond to conventional therapy Recommended in women with severe symptoms who failed other therapies (conditinal/low evidence)
PRESCRIPTION (RX) MEDICATIONS FOR IBS
Neuromodulators tricyclic antidepressants (desipramine, amitriptyline, etc.) Not approved for IBS Recommended (strong/moderate evidence)
SSRIs, SNRIs Not approved for IBS N/A
Antispasmodics dicyclomine IBS in adults Not recommended (conditional/low evidence)
hyoscyamine Not approved for IBS
OVER-THE-COUNTER (OTC) PRODUCTS
Herbal remedy peppermint Not approved for IBS Suggested (conditional/low evidence)
Opioid agonist loperamide Not approved for IBS Not recommended as first line
Probiotics Lactobacillus spp., Bifidobacterium spp., etc. Not approved for IBS Not suggested (conditional/very low evidence)

QUALITY OF EVIDENCE is expressed as23

  • High: Estimate of effect is unlikely to change with new data
  • Moderate: Likely to have an important impact on our confidence in the estimate of effect and may change the estimate
  • Low: Likely to have an important impact on our confidence in the estimate of effect and may change the estimate
  • Very low: Any estimate of effect is very uncertain

STRENGTH OF RECOMMENDATION is classified as22

  • Strong: Most patients should receive the recommended course of action
  • Conditional: Many patients will have this recommended course of action, but different choices may be appropriate for some patients

Clinical Practice Guidelines were published in 2021 by the American College of Gastroenterology (ACG). The recommendations were based on the GRADE methodology. This information is provided as a reference tool only and is not a substitute for clinical judgment. Each healthcare provider is solely responsible for any decisions made or actions taken in reliance of this information.

Downloadable Resources for You and Your Patients

An open dialogue focused on understanding the patient’s most bothersome symptoms may help reduce treatment delays and improve treatment expectations. The resources here are designed to help start the conversation and help with patient education and treatment management.

ACG=American College of Gastroenterology; IBS=irritable bowel syndrome; IBS-C=irritable bowel syndrome with constipation; IBS-D=irritable bowel syndrome with diarrhea.

References: 1. Ford AC et al. Am J Gastroenterol. 2018;113:1-18. doi:10.1038/s41395-018-0084-x 2. Weinberg DS, et al. Gastroenterology. 2014;147:1146-1148. doi:10.1053/j.gastro.2014.09.001 3. Chey WD et al. JAMA. 2015;313(9):949-958. doi:10.1001/jama.2015.0954 4. Moayyedi P et al. United European Gastroenterol J. 2017;5(6):773-788. doi:10.1177/2050640617731968 5. Adriani A et al. Panminerva Medica. 2018;60(4):213-222. doi:10.23736/S0031-0808.18.03541-3 6. Patel S et al. Consultant360. [published online December 4, 2018]. 7. Lacy BE et al. Gastroenterology. 2016;150(6):1393-1407. doi:10.1053/j.gastro.2016.02.031 8. Drossman DA. Am J Gastroenterol. 2013;108(4):521-528. doi:10.1038/ajg.2013.56 9. Farmer AD et al. CMAJ. 2020;192:E275-E282. doi:10.1503/cmaj.190716 10. Sleep and irritable bowel syndrome. http://www.aboutibs.org/signs-and-symptoms-main/sleep-and-irritable-bowel-syndrome-2.html 11. McKenzie YA et al. J Hum Nutr Diet. 2012;25:260-274. doi:10.1111/j.1365-277X.2012.01242.x 12. De Giorgio R et al. Gut. 2016;65(1):169-178. doi:10.1136/gutjnl-2015-309757 13. DeWeerdt S. Nature. 2016;533:S108-S109. doi:10.1038/533S108a 14. Pilcher H. Nature. 2016;533:S112-S113. doi:10.1038/533S112a 15. Böhn L et al. Am J Gastroenterol. 2013;108(5):634-641. 16. MacDermott RP. Inflamm Bowel Dis. 2007;13:91-96. doi:10.1002/ibd.20048 17. IBS in America survey summary findings. https://www.multivu.com/players/English/7634451-aga-ibs-in-america-survey/docs/survey-findings-pdf-635473172.pdf 18. Ballou S et al. Clin Trans Gastro. 2017;8:e214. doi:10.1038/ctg.2016.69 19. Mayer EA. N Engl J Med. 2008;358:1692-1699. 20. Park SH et al. Asian Nurs Res. 2014;8:182-192. 21. Lucak S et al. Therap Adv Gastroenterol. 2017;10:253-275. doi:10.1177/1756283X16663396 22. Lacy BE et al. Am J Gastroenterol. 2021;116(1):17-44. doi:10.14309/ajg.0000000000001036 23. Guyatt GH et al. BMJ. 2008;336(7650):924-926.