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
Serotonergic agents. Serotonin (5-hydroxytryptamine [5-HT]) modulates gastrointestinal secretions, gut motility, and visceral sensation. Researchers have developed IBS treatments that target receptors involved in these functions.
Tegaserod is a partial, selective 5-HT4 agonist indicated for the treatment of IBS-C in women. A study with 661 women with IBS-M and IBS-C showed that tegaserod increased the number of bowel movement episodes. Patients also reported higher stool consistency scores and fewer days with straining compared to placebo.27 The medication was removed from the market in 2007 because of its potential for cardiovascular adverse effects3; however, it was reintroduced in 2019 for women < 65 years of age with IBS-C. Consider prescribing tegaserod if other treatment options fail to alleviate symptoms.
Treatment of IBS-D
Antibiotics. The nonabsorbable antibiotic rifaximin is approved by the FDA for IBS-D at a dosage of 550 mg tid for 2 weeks.1 Several studies show improvement in IBS global symptoms with the recommended treatment course51-53; benefit persisted for the 10-week follow-up study period.1 A meta-analysis found that the NNT for rifaximin is 8-11.54 Preliminary data indicate that the rates of Clostridioides difficile infection and microbial resistance among rifaximin users are low.3 Consider using rifaximin as a first-line treatment option for patients with IBS-D. Retreatment might be necessary because the drug’s effect gradually disappears.9
Antidiarrheals. Eluxadoline is a µ-opioid and κ-opioid receptor agonist and δ-opioid receptor antagonist with effects on the intestinal nervous system.3 Several meta-analyses demonstrated that eluxadoline improves abdominal pain scores and daily stool consistency in IBS-D patients.53,54 Eluxadoline should be considered early in the management of IBS-D patients. The most common adverse effect is constipation.
The FDA issued a safety warning in 2017 regarding an increased risk of pancreatitis in patients taking eluxadoline who do not have a gallbladder. In addition, eluxadoline should be avoided in patients with a history of sphincter of Oddi dysfunction, alcohol abuse, or severe liver problems.3,54
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