Management options for IBS

Management strategies for IBS may include lifestyle and dietary changes, over-the-counter medications, and prescription medications1,2

The most appropriate management strategy may depend on several factors, including the patient’s predominant symptom(s) and how bothersome / severe the symptoms are, as well as patient preference and other considerations1-3

Lifestyle and behavioral modifications

Lifestyle changes, such as increasing exercise, reducing stress, or undertaking cognitive behavioral therapy, may help some patients with IBS to better manage their symptoms4,5

Select an item below for more information

How it works

Not fully understood; exercise is known to stimulate gastrointestinal motility and may thereby improve colonic transit (Asare 2012)

Clinical evidence snapshot

In a randomized trial of 102 patients with IBS, patients who increased their physical activity had significant reductions in IBS symptom severity scores (Johannesson 2011)

Clinical implication

Patients with IBS should be encouraged to increase their physical activity (e.g. a 20-minute walk each day) (Chey 2015)

References

Asare F et al. Curr Gastroenterol Rep 2012; 14: 283-289.
Johannesson E et al. Am J Gastroenterol 2011; 106: 915-922.
Chey WD et al. JAMA 2015; 313: 949-958.

How it works

Not fully understood; the brain–gut connection is known to play a central role in the pathophysiology of IBS (Mayer 2015)

Clinical evidence snapshot

In a meta-analysis of 32 trials of variable quality, psychological therapies, including cognitive behavioral therapy, hypnotherapy, and multicomponent psychotherapy, were found to be more effective than control therapies (Ford 2014; Chey 2015)

Clinical implication

Psychological therapies may provide an alternative or adjunctive therapy for some patients with IBS, especially those refractory to more conventional interventions (Chey 2015)

References

Mayer EA et al. Nat Rev Gastroenterol Hepatol 2015; 12: 592-605.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.
Chey WD et al. JAMA 2015; 313: 949-958.

Diet

Food can affect GI motility, permeability, visceral sensation, brain–gut interactions, microbiome, immune activation, and neuro-endocrine function, which have all been implicated in the pathogenesis of IBS symptoms6

Many patients with IBS self-report the onset or worsening of symptoms after ingestion of certain food types (e.g. fried or fatty foods), or after the ingestion of large meals7

Practicing good eating habits as well as reducing or avoiding so-called “trigger foods” may be beneficial for some patients to help reduce or prevent symptoms of IBS3

Select an item below for more information

How it works

Reducing intake of some common so-called “trigger foods” and practicing healthy eating habits may help to prevent or reduce symptoms of IBS (DeWeerdt 2016; Ford 2014)

Clinical evidence snapshot

In small clinical studies, some patients with IBS following traditional dietary advice, such as avoiding large meals, fat, insoluble fiber, caffeine, and gas-producing foods, report a reduction in symptoms/symptom severity (Böhn 2015)

Clinical implication

A true food allergy is no more common in patients with IBS than in the general population; however, providing patients with general dietary advice, such as eating regular meals and reducing intake of caffeine and carbonated drinks, is often the first step in helping to prevent or reduce symptoms (Chey 2015)

Changes in diet should be undertaken with the help of an experienced healthcare professional or a dietitian (DeWeerdt 2016; Chey 2015)

References

DeWeerdt S. Nature 2016; 533: S108-S109.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.
Böhn L et al. Gastroenterology 2015; 149: 1399-1407.
Chey WD et al. JAMA 2015; 313: 949-958.

How it works

Non-celiac gluten sensitivity in IBS is controversial; gluten-rich foods such as wheat also contain carbohydrates such as fructans and galactans, which in addition to gluten may trigger symptoms in some patients (Chey 2015; Gibson & Muir 2013; DeWeerdt 2016)

Clinical evidence snapshot

In a double-blind, placebo-controlled trial (n=34), patients with IBS on a gluten-free diet reported significantly improved symptom scores for abdominal pain, bloating, and stool consistency (Ford 2014; Biesiekierski 2011)

Another short-term study of gluten-free diet in patients with IBS found no impact on GI symptoms (Sanchez 2016)

Clinical implication

If general dietary changes have proved ineffective, a trial of a gluten-free diet may be considered for some patients with IBS

A gluten-free diet may be more convenient for patients to adhere to compared with a low-FODMAP diet (DeWeerdt 2016), although reduced intake of carbohydrates, rather than gluten, may be responsible for any symptom reduction (Chey 2015)

Changes in diet should be undertaken with the help of an experienced healthcare professional or a dietitian (DeWeerdt 2016; Chey 2015)

References

Chey WD et al. JAMA 2015; 313: 949-958.
Gibson PR, Muir JG. Gastroenterology 2013; 145: 693.
DeWeerdt S. Nature 2016; 533: S108-S109.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.
Biesiekierski JR et al. Am J Gastroenterol 2011; 106: 508-514.
Sanchez MIP et al. Gastroenterology 2016; 150: S743-S744.

How it works

FODMAPs are unabsorbable carbohydrates that act as substrates for bacterial fermentation and gas production, potentially triggering GI symptoms (El-Salhy 2015; Gibson & Shepherd 2005)

Clinical evidence snapshot

In a number of recent studies, a low-FODMAP diet was associated with improvement in IBS symptoms, such as bloating, abdominal pain, and flatulence (Böhn 2015; Vincenzi 2016; Galvez-Rios 2016)

Clinical implication

If general dietary changes have proved ineffective, a trial of a low-FODMAP diet may be considered (DeWeerdt 2016; McKenzie 2012)

A low-FODMAP diet is particularly restrictive and may not be suitable for long-term use; patients on a low-FODMAP diet should be monitored to ensure that adequate fiber, vitamins, and minerals are consumed, and gradual re-introduction of FODMAPs should be considered (DeWeerdt 2016)

A low-FODMAP diet should be undertaken with the help of an experienced healthcare professional or a dietitian (DeWeerdt 2016)

References

El-Salhy M. World J Gastroenterol 2015; 21: 7621-7636.
Gibson PR, Shepherd SJ. Aliment Pharmacol Ther 2005; 21: 1399-1409.
Böhn L et al. Gastroenterology 2015; 149: 1399-1407.
Vincenzi M et al. Gastroenterology 2016; 150: S425.
Galvez-Rios S et al. Gastroenterology 2016; 150: S742-S743.
DeWeerdt S. Nature 2016; 533: S108-S109.
McKenzie YA et al. J Hum Nutr Diet 2012; 25: 260-274.

Providing patients with a patient diary may help patients to identify problem foods and help them to better adhere to dietary guidance

Pharmacological treatments for IBS

The optimal management of patients with IBS requires an individualized approach that may encompass lifestyle, dietary, and medical interventions3,8

Select an item below for more information

Drug Indication/MoA
Alosetron

Indication
Women with severe IBS-D whose IBS symptoms have lasted 6 months or longer, who have had anatomic or biochemical abnormalities of the gastrointestinal tract excluded, and who have not responded adequately to conventional treatments (Prometheus 2016)

MoA
Selective serotonin 5-HT3 antagonist

Reference
Prometheus Laboratories, Inc. LOTRONEX® (alosetron hydrochloride) prescribing
information. January 2016.

Eluxadoline

Indication
Adults with IBS-D (Actavis 2016)

MoA
Mixed µ-opioid receptor (OR) and κ-OR agonist and δ-OR antagonist that acts locally in the gastrointestinal tract

Reference
Actavis Pharma, Inc. VIBERZI (eluxadoline) prescribing information. January 2016.

Loperamide

Indication
Control and symptomatic relief of acute nonspecific diarrhea and chronic diarrhea associated with inflammatory bowel disease (Janssen 1998)

MoA
Synthetic peripheral μ-OR agonist

Reference
Janssen Pharmaceutica Inc. IMODIUM® (loperamide hydrochloride) prescribing information. July 1998.

Rifaximin

Indication
Adults with IBS-D (Salix 2015)

MoA
Non-systemic, gastrointestinal-targeted antibiotic

Reference
Salix Pharmaceuticals. XIFAXAN® (rifaximin) prescribing information. November 2015.

Serum-derived bovine immunoglobulin/protein isolate

Indication
Prescription medical food product intended to provide for the distinctive nutritional requirements that are unique to the clinical dietary management of specific intestinal disorders (Entera 2015)

MoA
Though not fully understood, serum-derived bovine immunoglobulin isolate binds microbial components which may help to maintain immune balance and gut barrier function in the GI tract (Good 2015)

References
Entera Health, Inc. ENTERAGAM® (serum-derived bovine immunoglobulin/protein isolate) prescribing information. March 2015.
Good L et al. World J Gastroenterol 2015; 21: 3361-3366.

See full prescribing information for important safety information
Indications for listed products are selective for relevance

Drug Indication/MoA
Bulk-forming laxatives (e.g. psyllium)

Indication
Occasional constipation (drugs.com)

MoA
Psyllium, a bulk fiber laxative, is a mixture of soluble polysaccharides which help to increase stool water content (McRorie 1998)

References
Metamucil (psyllium). www.drugs.com/mtm/metamucil.html. Accessed March 2016.
McRorie JW et al. Aliment Pharmacol Ther 1998; 12: 491-497.

Osmotic laxatives (e.g. polyethylene glycol [PEG])

Indication
Occasional constipation (drugs.com)

MoA
Osmotic laxatives consist of poorly absorbed ions or molecules that lead to retention of water in the intestinal lumen (Ford 2014)

References
MiraLax (polyethylene glycol 3350). www.drugs.com/miralax.html. Accessed March 2016.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.

Stimulant laxatives (e.g. bisacodyl, docusate, senna)

Indication
Occasional constipation (drugs.com)

MoA
Stimulant laxatives induce fluid and electrolyte secretion into the colon or induce peristalsis in the colon (Ford 2014)

References
www.drugs.com. Accessed March 2016.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.

Linaclotide

Indication
Adults with IBS-C and chronic idiopathic constipation

MoA
Selectively binds with high affinity to the guanylate cyclase-C receptor (Ironwood 2016)

Reference
Ironwood Pharmaceuticals, Inc. and Forest Pharmaceuticals, Inc. LINZESS® (linaclotide) prescribing information. April 2016.

Lubiprostone

Indication
IBS-C in women ≥18 years old and chronic idiopathic constipation

MoA
Chloride channel type 2 activator (Sucampo 2013)

Reference
Sucampo Pharmaceuticals, Inc. and Takeda Pharmaceuticals, Inc. Amitiza® (lubiprostone) prescribing information. April 2013.

See full prescribing information for important safety information
Indications for listed products are selective for relevance

Management is generally aimed at improving one or more of the predominant symptoms, such as abdominal pain, constipation, and diarrhea (Chang 2014)

However, there should be a higher threshold in prescribing agents to treat diarrhea and constipation, as additional symptoms could be induced (e.g. anti-diarrheal causing constipation) (Saha 2014)

References

Chang L et al. Gastroenterology 2014; 147: 1149-1172.
Saha L. World J Gastroenterol 2014; 20: 6759-6773.

Drug Indication/MoA
Antispasmodics (e.g. dicyclomine)

Indication
Dicyclomine is indicated for functional bowel/irritable bowel syndrome (Aptalis Pharma 2016)
Indication for other antispasmodics may vary (drugs.com)

MoA
Muscarinic acetylcholine receptor antagonists (Trinkley & Nahata 2014)

References
Aptalis Pharma US, Inc. BENTYL® (dicyclomine hydrochloride) prescribing information. January 2016.
www.drugs.com. Accessed March 2016.
Trinkley KE, Nahata MC. Digestion 2014; 89: 253-267.

Probiotics

Indication
Over-the-counter products to aid digestion and relieve symptoms of IBS (drugs.com)

MoA
The precise MoA of probiotics is unknown; suggested mechanisms include alteration of gut mucosal barrier function, the gut microbiome, and mucosal immune function (Chey 2011)

References
www.drugs.com. Accessed March 2016.
Chey WD. Gut Liver 2011; 5: 253-266.

Triple-coated enteric peppermint oil (e.g. IBgard®)

Indication
Over-the-counter product used for a variety of GI symptoms and IBS (drugs.com)

MoA
Peppermint oil may relax smooth muscle and also may attenuate visceral hypersensitivity and modulate pain sensation (Ford 2014)

References
www.drugs.com. Accessed August 2016.
Ford AC et al. Am J Gastroenterol 2014; 109 Suppl 1: S2-S26.

See full prescribing information for important safety information
Indications for listed products are selective for relevance

The AGA/ACG recommendations

The American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) independently published recommendations for the treatment of IBS in 20141,2

  • The AGA made conditional or strong recommendations for pharmacologic treatments as compared with no treatment at all2
  • The ACG assessed specific statements pertaining to each treatment’s effectiveness and made a recommendation of “weak” or “strong” for each statement1

The AGA and ACG guidelines were published prior to the approvals of rifaximin and eluxadoline, which were approved for IBS-D in 2015

Overall, management of patients with IBS should be optimized by an individualized, holistic approach including dietary, lifestyle, behavioral, and medical interventions3

IBS-C Treatment Options

Click image to view the current FDA-approved and commonly used pharmacologic treatments for IBS-D

IBS-D Treatment Options

Click image to view the current FDA-approved and commonly used pharmacologic treatments for IBS-C

This information 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. Drugs described may have indications not related to IBS. Always refer to full prescribing information for important safety information for any pharmacological treatment. 

Learn more about IBS

References

  1. Ford AC et al. Am J Gastroenterol 2014; 109: S2-S26.
  2. Weinberg DS et al. Gastroenterology 2014; 147: 1146-1148.
  3. Chey WD et al. JAMA 2015; 313: 949-958.
  4. Dorn SD. Aliment Pharmacol Ther 2010; 32: 513-521.
  5. Johannesson E et al. Am J Gastroenterol 2011; 106: 915-922.
  6. Chey WD. Am J Gastroenterol 2016; 111: 366-371.
  7. Böhn L et al. Am J Gastroenterol 2013; 108: 634-641.
  8. Lucak S et al. Therap Adv Gastroenterol 2016; in press.