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
Peppermint oil has been found useful in improving IBS global symptoms and abdominal pain in several studies.44-46 A common adverse effect of peppermint oil is heartburn, resulting from relaxation of esophageal muscle.3 Peppermint oil can be considered an adjuvant agent in treating IBS.
Antidepressants. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) have been studied for the treatment of IBS. Meta-analyses show that both are effective in reducing pain and overall IBS symptoms.1,3,47 The number needed to treat (NNT) for TCAs is 4.5; for SSRIs, 5.47 Data do not show that either drug class is superior to the other for IBS. Based on the adverse effect profile, TCAs are more suitable for IBS-D patients; SSRIs are better for IBS-C patients.47
New data show that serotonin-norepinephrine reuptake inhibitors, such as duloxetine and milnacipran, can alleviate IBS symptoms through their pain-modifying properties.47
Based on the adverse effect profile and stigma associated with antidepressant medications, patients might be less likely to take them for IBS symptoms than for these drugs’ primary indications. Clinicians should still consider this drug class if other first-line treatments do not provide full resolution of symptoms.
Psychotherapy. Several psychotherapeutic modalities have been evaluated for efficacy in reducing global IBS symptoms. The approaches studied most often were provider-directed cognitive behavioral therapy, relaxation therapy, hypnotherapy, and multicomponent psychological therapy. The NNT for these modalities is 4, but studies had significant heterogeneity.3 Consider referring patients for psychotherapeutic intervention if they have not responded to medical therapy after 12 months.4
Continue to Treatment of IBS-C
