How to meet the challenges of managing patients with IBS
Establish a strong relationship with your patient. Rule out “red-flag” diagnoses. Then choose from one of the therapies detailed here to target the subtype of disease.
PRACTICE RECOMMENDATIONS
› Make the diagnosis of irritable bowel syndrome (IBS) based on clinical findings, after excluding red flags in the presentation. C
› Screen patients with diarrhea-predominant IBS with fecal and serologic studies to rule out inflammatory bowel disease and celiac disease. B
› Counsel all IBS patients to increase their intake of soluble fiber, follow a low-FODMAP (fermentable oligo-, di-, and monosaccharide, and polyol) diet, and increase physical activity. B
› Prescribe an antispasmodic to treat mild IBS of all subtypes. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Acupuncture. In a meta-analysis with 3440 patients, acupuncture was more effective than Western medicine in alleviating IBS symptoms for as long as 3 months. The authors concluded that acupuncture could be used in combination with other therapies to reduce the severity of IBS symptoms.56
Concomitant acupuncture and Chinese herbal medicine. In a systematic review and meta-analysis comprising 21 randomized controlled trials, researchers reported that acupuncture combined with Chinese herbal medicine improved IBS symptoms, compared to what was noted in matched controls who were treated with Western medicine or with Western medicine combined with Chinese herbal medicine. The authors were cautious about the results of the meta-analysis, however, because the studies examined were small and of low quality, and presented a high risk of bias.57
Agents not to be used routinely for IBS
Loperamide. This peripheral µ-opioid receptor agonist controls diarrhea. However, recent studies showed no significant benefit to loperamide over placebo in IBS-M and IBS-D. In 2018, the FDA issued a safety alert regarding an elevated risk of serious cardiac adverse effects in patients taking loperamide. The ACG recommends against using loperamide to treat IBS symptoms.3,54
Polyethylene glycol. An osmotic laxative that is not absorbed in the intestinal lumen, polyethylene glycol is highly efficacious for alleviating constipation, but it does not reduce pain or other IBS symptoms. For that reason, the ACG recommends against its use.3
CORRESPONDENCE
Jose M. Villalon-Gomez, MD, MPH, Emory Healthcare Family Medicine, 4500 North Shallowford Road, Dunwoody, GA 30338; jose.villalon-gomez@emory.edu
