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
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.21
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.21
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.22 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.22 A regular follow-up should be conducted to assess patient progress, depending on the patient’s personal and symptom history.22 If patient symptoms are not improving, additional or alternative treatment options should be considered.22
GUIDELINE Recommendations for Management of IBS-C
Clinical Practice Guidelines were published in 2022 by the American Gastroenterological Association (AGA).23 The recommendations were based on the GRADE methodology.24 See the full AGA Guidelines for more information.
| Class | Medication | Use/Indication | ACG 2022 Guideline Recommendations23 |
|---|---|---|---|
| PRESCRIPTION (RX) MEDICATIONS FOR IBS-C | |||
| Secretagogues - GC-C agonists | linaclotide | IBS-C in adults | Recommended (strong/high evidence) |
| plecanatide | IBS-C in adults | Suggested (conditional/moderate evidence) | |
| NHE3 inhibitors | tenapanor | IBS-C in adults | Suggested (conditional/moderate evidence) |
| 5-HT4 agonists | tegaserod | IBS-C in adult women <65 years of age | Suggested in women <65 years without a history of CV ischemic events [such as MI, stroke, TIA, or angina] (conditional/moderate evidence) |
| Secretagogues - Cl channel activators | lubiprostone | IBS-C in adults | Suggested (conditional/moderate evidence) |
| PRESCRIPTION (RX) MEDICATIONS FOR IBS | |||
| Neuromodulators | tricyclic antidepressants (desipramine, amitriptyline, etc) | Not approved for IBS | Suggested (conditional/low evidence) |
| SSRIs | Not approved for IBS | Not suggested (conditional/low evidence) | |
| Antispasmodics | dicyclomine | IBS in adults | Suggested (conditional/low evidence) |
| hyoscyamine | Not approved for IBS | ||
| OVER-THE-COUNTER (OTC) PRODUCTS | |||
| Osmotic laxatives | PEG laxatives | Not approved for IBS | Suggested (conditional/low evidence) |
CERTAINTY OF EVIDENCE is expressed as:23
- High: Very confident that the true effect lies close to that of the estimate of the effect
- Moderate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
- Low: The true effect may be substantially different from the estimate of the effect
- Very low: The true effect is likely to be substantially different from the estimate of the effect
STRENGTH OF RECOMMENDATION is classified as:23
- Strong: Most patients should receive the intervention
- Conditional: Different choices will be appropriate for individual patients consistent with their values and preferences
Data across treatment groups should not be compared. For all recommendations, the treatment is recommended or suggested “over no drug treatment.” 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.
Clinical Practice Guidelines were published in 2021 by the American College of Gastroenterology (ACG).21 The recommendations were based on the GRADE methodology.26 See the full ACG Guidelines for more information.
| Class | Medication | Use/Indication | ACG 2021 Guideline Recommendations21 |
|---|---|---|---|
| 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 (strong/conditional/low) |
| PRESCRIPTION (RX) MEDICATIONS FOR IBS | |||
| Neuromodulators | tricyclic antidepressants (desipramine, amitriptyline, etc.) | Not approved for IBS | Recommended (strong/moderate evidence) |
| SSRIs | 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 softeners | docusate | Not approved for IBS | N/A |
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.
| Treatment | 2022 AGA Guidelines23,24 (recommendation/level of evidence) |
2021 ACG Guideline21,26 (recommendation/level of evidence) |
|---|---|---|
| GC-C Agonists |
|
Recommend using (stronga/highg) |
| Tenapanor | Suggest using (conditionalb/moderated) | N/A |
| Tegaserod | Suggest using (conditionalb/moderated) | Suggest using (conditionalf/lowh) |
| Lubiprostone | Suggest using (conditionalb/moderated) | Recommend using (stronga/moderatei) |
| PEG Laxatives | Suggest using (conditionalb/lowe) | Suggest against (conditionalf/lowh) |
aMost patients should receive the intervention. bDifferent choices will be appropriate for patients consistent with their values and preferences. cVery confident that the true effect lies close to that of the estimate of the effect. dThe true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. eThe true effect may be substantially different from the estimate of the effect. fMany patients will have this recommended course of action, but different choices may be appropriate for some patients. gEstimate of effect is very unlikely to change with new data. hFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. iFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Linaclotide Indications and Safety25
Linaclotide is a guanylate cyclase-C agonist indicated for the treatment of:
- Irritable bowel syndrome with constipation (IBS-C) in adults
- Chronic idiopathic constipation (CIC) in adults
WARNING: RISK OF SERIOUS DEHYDRATION IN PEDIATRIC PATIENTS LESS THAN 2 YEARS OF AGE
Linaclotide is contraindicated in patients less than 2 years of age; in non-clinical studies in neonatal mice, administration of a single, clinically relevant adult oral dose of linaclotide caused deaths due to dehydration.
Contraindications
Linaclotide is contraindicated in patients:
- Less than 2 years of age due to the risk of serious dehydration
- With known or suspected mechanical gastrointestinal obstruction
Warnings and Precautions
Pediatric Risk: The safety and effectiveness of linaclotide in patients less than 18 years of age have not been established.
Diarrhea: Diarrhea was the most common adverse reaction in linaclotide-treated patients in pooled IBS-C and pooled CIC double-blind placebo-controlled trials. If severe diarrhea occurs, dosing should be suspended, and the patient rehydrated.
GUIDELINE Recommendations for Management of IBS-D
Clinical Practice Guidelines were published in 2022 by the American Gastroenterological Association (AGA).27 The recommendations were based on the GRADE methodology.24 See the full AGA Guidelines for more information.
| Class | Medication | Use/Indication | ACG 2022 Guideline Recommendations27 |
|---|---|---|---|
| PRESCRIPTION (RX) MEDICATIONS FOR IBS-D | |||
| Mixed opioid agonist/antagonist | eluxadoline | IBS-D in adults | Suggested. Contraindicated in patients without a gallbladder or those who drink more than 3 alcoholic beverages per day (conditional/moderate evidence) |
| Non-absorbable antibiotics | rifaxamin | IBS-D in adults | Suggested for retreatment in patients with an initial response to rifaximin who develop recurrent symptoms (conditional/moderate evidence) |
| 5-HT3 agonists | alosetron | Severe IBS-D in women who do not respond to conventional therapy | Restricted for use in women with severe IBS-D under a risk-management program (conditional/moderate evidence) |
| PRESCRIPTION (RX) MEDICATIONS FOR IBS | |||
| Neuromodulators | tricyclic antidepressants | Not approved for IBS | Suggested (conditional/low evidence) |
| SSRIs | Not approved for IBS | Not suggested (conditional/low evidence) | |
| Antispasmodics | dicyclomine | IBS in adults | Suggested (conditional/low evidence) |
| hyoscyamine | Not approved for IBS | ||
| OVER-THE-COUNTER (OTC) PRODUCTS | |||
| Opioid agonist | loperamide | Not approved for IBS-D | Suggested (conditional/very low evidence) |
CERTAINTY OF EVIDENCE is expressed as:27
- High: Very confident that the true effect lies close to that of the estimate of the effect
- Moderate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
- Low: The true effect may be substantially different from the estimate of the effect
- Very low: The true effect is likely to be substantially different from the estimate of the effect
STRENGTH OF RECOMMENDATION is classified as:27
- Strong: Most patients should receive the intervention
- Conditional: Different choices will be appropriate for individual patients consistent with their values and preferences
Data across treatment groups should not be compared. For all recommendations, the treatment is recommended or suggested “over no drug treatment.” 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.
Clinical Practice Guidelines were published in 2021 by the American College of Gastroenterology (ACG).21 The recommendations were based on the GRADE methodology.26 See the full ACG Guidelines for more information.
| Class | Medication | Use/Indication | ACG 2021 Guideline Recommendations21 |
|---|---|---|---|
| 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 agonists | 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) |
| Bile Acid Sequestrants | colestipol, colesevelam | IBS-D in adults | Suggested against (conditional/very 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) |
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.
| Treatment | 2022 AGA Guidelines24,27 (recommendation/level of evidence) |
2021 ACG Guideline21,26 (recommendation/level of evidence) |
|---|---|---|
| Eluxadoline | Suggest using (Conditionala/Moderateb) | Suggest using (Conditionald/Moderatef) |
| Rifaximin | Suggest using (Conditionala/Moderateb) | Recommend using (Stronge/Moderatef) |
| Alosetron | Suggest using (Conditionala/Moderateb) | Recommend using (Conditionald/Lowf) |
| Loperamide | Suggest using (Conditionala/Very lowc) | Not recommended as first-line therapy |
| Bile Acid Sequestrants | N/A | Suggests against (Conditionald/Very Lowg) |
aDifferent choices will be appropriate for patients consistent with their values and preferences. bThe true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. cThe true effect is likely to be substantially different from the estimate of the effect. dMany patients will have this recommended course of action, but different choices may be appropriate for some patients. eMost patients should receive the recommended course of action. fFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. gAny estimate of effect is very uncertain.
Eluxadoline Indications and Safety28
Eluxadoline is a mu-opioid receptor agonist, as well as a kappa-opioid receptor agonist and a delta-opioid receptor antagonist, indicated for the treatment of:
- Irritable bowel syndrome with diarrhea (IBS-D) in adults
Eluxadoline is a C-IV prescription medication approved by the Food and Drug Administration (FDA) on May 27, 2015.
Contraindications
Eluxadoline is contraindicated in patients:
- Without a gallbladder
- With known or suspected biliary duct obstruction, or sphincter of Oddi disease or dysfunction
- With alcoholism, alcohol abuse, alcohol addiction, or in patients who drink more than 3 alcoholic beverages per day
- A history of pancreatitis or structural diseases of the pancreas, including known or suspected pancreatic duct obstruction
- With a known severe hypersensitivity reaction to eluxadoline
- With a severe hepatic impairment
- With a history of chronic or severe constipation or sequelae from constipation, or known or suspected mechanical gastrointestinal obstruction
Warnings and Precautions
- Pancreatitis and Sphincter of Oddi Spasm: Monitor patients for new or worsening abdominal pain, with or without nausea and vomiting, or acute biliary pain with liver or pancreatic enzyme elevations; immediately discontinue eluxadoline and seek medical attention if symptoms develop.
- Hypersensitivity Reactions, including anaphylaxis: Immediately discontinue eluxadoline and seek medical attention if symptoms develop.
- Constipation: Instruct patients to stop eluxadoline and immediately contact their healthcare provider if they develop severe constipation. Avoid use with other drugs that may cause constipation.
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.