The management of irritable bowel syndrome typically includes many different components. And, which of the many treatment options is used needs to be individualized for each patient.
Broadly speaking, the components of the treatment plan may include
1. Patient education
3. Dietary fiber
4. Prescription medications
6. Psychological treatments.
As in all chronic medical conditions, patient education is very important. Instead of having patient’s Google the disorder here are two really good sources we can refer them to:
– American College of Gastroenterology. Irritable Bowel Syndrome.
– Medlineplus.gov. Irritable Bowel Syndrome.
A trial of a low FODMAP diet is recommended for persons with irritable bowel syndrome (Moayyedi et al., 2019). FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, polyols. For details of the low FODMAP diet and how exactly to implement it, please see the following article on this website:
Note: If testing for celiac disease is negative, there is no need for a gluten-free diet.
We all know that dietary fiber has various health benefits. But, for persons with irritable bowel syndrome who have constipation, soluble, viscous, and poorly fermentable fiber is recommended as a first-line treatment, but insoluble and fermentable fiber is not (Lacy et al., 2021).
For a discussion of soluble and insoluble fiber and the foods in which they are found, please see the following article on this website:
And, for a practical guide to fiber supplements, please see:
It is helpful for mental health clinicians to know about prescription medications because of some of them (antidepressants) we may prescribe and others our patients may be on. Often, my patients used to come in saying they were on one of these newer medications and I would have to look them up.
An important factor in choosing medications for a particular patient is whether the person has diarrhea-predominant or constipation-predominant irritable bowel syndrome (Moayyedi et al., 2019).
A helpful rule of thumb for using antidepressants in persons with irritable bowel syndrome is that (Staudacher et al., 2021):
– Tricyclic antidepressants (TCAs) may be most helpful if the main symptoms are diarrhea and abdominal pain
– Selective serotonin reuptake inhibitors (SSRIs) may be helpful if constipation symptoms are prominent AND anxiety/ depression need to be treated with an antidepressant
– Serotonin-norepinephrine reuptake inhibitors (SNRIs) may be considered when abdominal pain is the most significant symptom though, as of January 2022, their efficacy in irritable bowel syndrome has not been clearly shown (Staudacher et al., 2021).
Other prescription medications
1. For irritable bowel syndrome with constipation symptoms, the following two classes of medications are recommended (Lacy et al., 2021):
– Chloride channel activators including lubiprostone (Amitiza®). The average price for a month’s supply in the United States is about $250 (as of January 2022).
– Guanylate cyclase activators/ agonists including linaclotide (Linzess®). The average price for a month’s supply in the United States is about $500 (as of January 2022).
2. For irritable bowel syndrome with diarrhea symptoms:
– A non-absorbable, gastrointestinal antibiotic called rifaximin (Xifaxan®) is recommended (Lacy et al., 2021). The average price for a month’s supply in the United States is over $2000 (as of January 2022).
– A mu-opioid receptor agonist called eluxadoline (Viberzi®) has an FDA indication for the treatment of irritable bowel syndrome with diarrhea. The average price for a month’s supply in the United States is about $1500 (as of January 2022).
Antispasmodics are very frequently used to reduce abdominal cramping and gastrointestinal motility.
But, due to limited research data, the American College of Gastroenterology clinical guideline for irritable bowel syndrome recommends against the use of antispasmodics available in the United States (as of January 2022), which are dicyclomine, hyoscyamine, and hyoscine (Lacy et al., 2021).
TO BE COMPLETED
What is NOT recommended
For most patients with irritable bowel syndrome, the following interventions are NOT recommended (Moayyedi et al., 2019):
– Osmotic laxatives
– “Gut-directed psychotherapy” is recommended for the treatment of global irritable bowel syndrome symptoms (Lacy et al., 2021).
– Cognitive-behavior therapy
– Hypnotherapy (if available)
Peppermint oil has been recommended for irritable bowel syndrome because it might reduce overall symptoms of irritable bowel syndrome and abdominal pain (Lacy et al., 2021; Khanna et al., 2014). But, we are not sure about this; the evidence is mixed.
Also, peppermint oil is well-tolerated but it may cause heartburn in some patients due to its effects on the esophagus and lower esophageal sphincter (Lacy et al., 2021). So, it is important to recommend enteric-coated formulations of peppermint oil, which may be less likely to cause heartburn because the oil is not released until the pill has moved on from the stomach (Lacy et al., 2021). As you might guess, if enteric-coated peppermint oil is taken along with antacids, the enteric coating may dissolve prematurely.
One popular brand of enteric-coated peppermint oil is IBgard Daily Gut Health Support® (Nestlé Health Science).
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