Irritable bowel syndrome (IBS)

Use at a glance

• Diet/lifestyle + reassurance are foundational

Practical pearls

• Treat predominant stool pattern
• IBS-C: fiber/PEG for stool; secretagogues for global symptoms

Other practical pearls

• Low-dose neuromodulators can reduce pain
• Alarm features require evaluation beyond IBS

Choosing treatment

• IBS-D: loperamide for stool; rifaximin/eluxadoline in selected patients

Key points

• 1st: low-FODMAP diet, exercise, soluble fiber, peppermint oil (↓ pain)
• Probiotics may ↓ pain/bloating/flatulence (no strain proven best); FMT mixed results; IBS-specific CBT effective
• PRN antispasmodics (dicyclomine, hyoscyamine) for acute pain; anticholinergic AEs
• TCAs ↓ abdominal pain in moderate–severe IBS
• IBS-C: PEG ↑ stool frequency only; then lubiprostone, linaclotide, plecanatide, or tenapanor (modest)
• IBS-D: loperamide ↓ stool frequency only; rifaximin ×14 d effective, recurrence common
• IBS-D also: bile acid sequestrants (diarrhea only); eluxadoline (pancreatitis risk); alosetron, severe refractory women

Nonpharmacologic therapies

• Low-FODMAP diet
• Gluten-free diet
• Exercise or yoga
• Soluble fiber
• Probiotics
• Fecal microbiota transplant
• IBS-specific CBT
• Hypnotherapy or relaxation training

Pearls

• Gluten-free diet unproven; low-FODMAP is the evidence-based diet
• Psyllium helps, bran doesn't; titrate slowly to limit bloating
• SSRIs generally not recommended; TCAs preferred for pain
• GC-C agonist diarrhea: lower dose or take with food
• Antispasmodics best taken before meals

Self-check

• What guides IBS treatment?
  Predominant stool pattern.
• What do alarm features require in suspected IBS?
  Evaluation beyond IBS.

Drugs used for this (23)

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