How to meet the challenges of managing patients with IBS

The Journal of Family Practice. 2021 November;70(9):431-441 | doi: 10.12788/jfp.0299

November 12, 2021|Family Medicine

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

The high cost of eluxadoline can be a significant barrier to use.

Serotonergic agents. Alosetron is a selective 5-HT₃ antagonist developed to treat IBS-D.³ In a meta-analysis comprising 9844 patients, alosetron showed superior abdominal pain scores and improved stool consistency compared to ramosetron, rifaximin, and eluxadoline.⁵³ In 2001, the FDA withdrew alosetron, due to severe constipation and a risk of ischemic colitis; however, the medication has become commercially available again through a risk evaluation and mitigation strategy (REMS) program for women who have disabling IBS-D symptoms.^3,54 Because of this special circumstance, alosetron is not considered first-line therapy for IBS-D.

Linaclotide, plecanatide, and lubiprostone should be considered firstline therapies for IBS-C.

Ondansetron has also been used to treat IBS-D. In a meta-analysis with 294 patients, ondansetron showed improvement in stool consistency.⁵⁵ Ondansetron does not improve abdominal pain.⁴ It can be used in patients who have mild-to-moderate symptoms.⁹ Ondansetron is not FDA approved for the treatment of IBS-D.

Bile-acid sequestrants. Traditionally, bile-acid sequestrants have been used to treat bile-acid diarrhea. A meta-analysis of 6 studies of 908 patients with IBS-D found that 28.1% were affected by bile-acid malabsorption. Two small studies that evaluated the benefits of colesevelam for IBS-D found significant improvement in stool consistency.⁵⁴Another study, which evaluated the benefits of cholestyramine, found improvement in stool consistency, but findings were not significant.⁵⁴ Many patients taking a bile-acid sequestrant stop taking the medication because of considerable adverse effects (constipation, nausea, bloating, flatulence, and abdominal pain).⁵⁴For that reason, this class of medication is not recommended as first-line treatment for IBS-D and is not FDA approved for IBS-D.

SIDEBAR
KEY POINTS The challenge of, and a needed framework for, managing IBS

IBS is a complex, chronic condition affecting a considerable number of people worldwide.
Because of the substantial disease burden associated with IBS, patients are at higher risk of mental health disorders.
Physicians who care for IBS patients must build a strong physician–patient relationship; their mutual trust will ensure development of an effective treatment plan.
Family physicians and other primary care providers are equipped to help IBS patients navigate the complex health care system and the IBS disease process. They can help coordinate care with specialists and behavioral health clinicians, which will help patients improve quality of life and manage symptoms appropriately.

A role for complementaryand integrative medicine?

Recently, complementary and integrative modalities for treating IBS have sparked the interest of researchers.

Continue to: Acupuncture

References

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