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.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
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
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.