The American Gastroenterological Association (AGA) published two sets of guidelines in the journal Gastroenterology: one for IBS-C, where patients experience constipation; and one for IBS-D, which involves diarrhea. These guidelines detail for the first time what interventions patients should try, as well as the best times to consider newer drugs as opposed to older medications, according to a statement from the AGA. Irritable bowel syndrome (IBS), which affects up to 35 million Americans, is a chronic gastrointestinal condition that impairs proper functioning of the small and large intestines, often causing cramps, diarrhea, constipation, and irregular bowel movements. Many people miss school, work, and social events because of its debilitating effects. For many people with IBS, what’s known as a low-FODMAP diet is the first thing they should try to manage symptoms, the new guidelines recommend. A high-FODMAP diet contains lots of foods that can cause digestive distress, and limiting these foods can often help alleviate IBS symptoms, according to the AGA. “Some patients with IBS have mild symptoms and can learn to manage and reduce their symptoms with nonpharmacologic therapies,” says Lin Chang, MD, an author on both sets of new guidelines and vice-chief of the division of digestive disease at the David Geffen School of Medicine at the University of California in Los Angeles.
Start by Changing Your Lifestyle
Even patients who have moderate to severe IBS symptoms can often benefit from focusing on lifestyle changes like adopting a low-FODMAP diet, getting more exercise, improving sleep, and reducing stress, Dr. Chang says. FODMAP is an acronym that highlights certain types of carbohydrates and sugars that aren’t easily absorbed in the small intestines and can cause digestive distress in people with IBS. FODMAP stands for:
Fermentable: creates gasOligosaccharides: certain kinds of fiber in beans, onion, wheat, and garlicDisaccharide: lactose, a type of sugar found in milk, yogurt, and ice creamMonosaccharide: fructose, a type of sweetener in mango, apples, pears, and watermelonAndPolyols: sweeteners found in sugar-free gum that are also found in plums, nectarines, and cauliflower
Depending on a person’s main symptoms, next steps in treatment for mild IBS can include over-the-counter laxatives or anti-diarrheal medicines. People with mild symptoms may also try over-the-counter-peppermint oil tablets or older prescription medicines known as antispasmodics, both of which can ease abdominal pain by preventing muscle spasms in the bowel. People may try these remedies before seeing an IBS specialist or gastroenterologist. But if lifestyle changes and over-the-counter and prescription medications don’t help restore normal bowel function, they should see a specialist to develop a personalized treatment plan, the guidelines stress. “There is no one-size-fits-all plan of management,” says Peter Gibson, MD, a professor of gastroenterology at Monash University in Australia, who wasn’t involved in the guidelines. But starting with lifestyle changes and behavioral therapy to support these efforts can bring many patients relief and a better understanding of their own symptoms before they try more aggressive treatment, Dr. Gibson says.
When Lifestyle Changes Aren’t Enough
If IBS-C symptoms still persist, the guidelines recommend prescription pills known as secretagogues, which work by increasing fluids inside the digestive tract to help things move more easily through the intestines. These include linaclotide (Linzess), lubiprostone (Amitiza), and plecanatide (Trulance). For women under 65 years old who have severe IBS-C symptoms, the guidelines suggest they try another prescription drug, tegaserod (Zelnorm) that gets stool moving through the bowels and can help reduce bloating and abdominal pain. To treat severe IBS-D symptoms, the course of treatment may include the antibiotic rifaximin, which is often used to treat bacterial gastrointestinal infections. Older medicines known as tricyclic antidepressants may also help at this stage to help regulate bowel function. Doctors may also prescribe alosetron (Lotronex) to help relieve diarrhea, cramps, pain, and the sensation of urgently needing to have a bowel movement, the guidelines advise. Finally, people with moderate to severe IBS who experience persistent abdominal pain or psychological distress may be prescribed tricyclic antidepressants or newer antidepressants in a family of medicines known as serotonin-noradrenaline reuptake inhibitors, which can ease pain in addition to depression and anxiety. What’s known as brain-gut behavioral therapies, such as cognitive behaviorial therapy or hypnotherapy, which focuses on shifting how patients think and feel about symptoms, can also be used for moderate to severe IBS, the guidelines suggest. While none of the approaches highlighted in the guidelines can cure IBS, people can often find a treatment plan that makes their symptoms far less frequent and severe and offers great improvement to their quality of life, says Lawrence Schiller, MD, a gastroenterologist and chair of institutional review boards for human subject protection at the Baylor Scott and White Research Institute in Dallas. “The situation today is much better for IBS patients than at any time in the past,” says Dr. Schiller, who wasn’t involved in drafting the new guidelines. “We have medications that can be effective in relieving symptoms in most. In addition, strategic use of dieticians and psychologists can improve outcomes.”
