Treatment of Irritable Bowel Syndrome

Educational Objectives

The goal of this program is to improve management of irritable bowel syndrome. After hearing and assimilating this program, the clinician will be better able to:

1. Choose an appropriate treatment for irritable bowel syndrome with constipation or diarrhea
2. Identify the latest modifications in risk evaluation and mitigation strategy

Summary

Victimization and irritable bowel syndrome (IBS): physical, emotional, and sexual victimization contribute to IBS; people experiencing victimization are twice as likely to experience IBS; nondisclosure of victimization leads to worsening of symptoms

Treatment of IBS: difficulties include lack of validated algorithms and varied responses to treatments among patients; treatment targets predominant symptom; often requires more than one medication; should include diet, skillful patient communication, complementary and alternative medicine, and psychotherapy

Probiotics, prebiotics, and synbiotics: probiotics improve bloating and flatulence but the recommendation for their use is weak and the quality of evidence is low; Doron and Snydman (2015) report the development of autoimmune illnesses and infection in immunocompromised patients as theoretical risks of using probiotics; prebiotics are nondigestible carbohydrates present in foods that provide health benefits by promoting growth of microorganisms (eg, Jerusalem artichoke, garlic, leeks); synbiotics are a combination of probiotics and prebiotics (eg, yogurt, whole grains, bananas)

Natural remedies: Coëffier et al (2015) showed that glutamine in various doses is effective in IBS; Ford et al (2018) reported that peppermint oil and capsules can successfully treat IBS with diarrhea (IBS-D); the main component of peppermint oil is menthol, which inhibits smooth muscle contractility and induces analgesia; peppermint oil is recommended by the American College of Gastroenterology guidelines for overall symptom improvement; however, recommendations are weak owing to significant heterogeneity in study results; use of peppermint oil is associated with increased reflux; STW-5 (Iberogast), a herbal supplement, is available online only; it has an antispasmodic effect on the gastrointestinal (GI) tract and was reported to be effective in IBS by Doron and Snydman (2015)

Standard medications for IBS-D: loperamide hydrochloride (Imodium) is a synthetic antidiarrheal and an opioid receptor agonist; it increases absorption of water and slows intestinal motility but has no effect on abdominal pain; it may cause constipation, which can be easily remedied by lowering the dose; it is an over-the-counter drug but can be abused in higher doses; diphenoxylate and diphenoxylate-atropine are schedule IV controlled substance alternatives; risks of using these medicines include cardiac arrhythmias, cardiac arrest, and even death

Bile salt agents: malabsorption of bile acid (BA) is increasingly being recognized as a source of IBS; SeHCAT test is a validated test but is not yet available in the United States; other tests for malabsorption of BA are not yet clinically validated; a BA binder may be used empirically; adverse GI effects include bloating, abdominal pain, and constipation

New treatments for IBS-D: eluxadoline (Viberzi) is a mixed opioid receptor agonist/antagonist; it should not be used in patients without a gallbladder or in those with Oddi sphincter problems, biliary obstruction, history of pancreatitis, alcoholism, severe liver disease, or consumption of >3 alcoholic drinks daily; most common adverse effect is constipation, usually after long-term use; alosetron (Lotronex) is a selective serotonin 5-HT₃ receptor antagonist recommended in women with IBS lasting ≥6 mo that does not respond to usual therapy; prescribed at a dose of 0.5 to 1 mg twice daily; should not be used in ischemic colitis; according to the modified risk evaluation and mitigation strategy, stickers are no longer required on the prescription and electronic prescriptions are allowed; rifaximin (Xifaxan) corrects changes in the gut microbiome; it is a nonabsorbable antibiotic with modest efficacy; it is particularly useful for treating bloating but symptom relief lasts only ≤10 weeks leading to frequent recurrences; of patients treated with rifaximin, Lembo et al (2016) reported that 64% eventually relapse; retreatment is effective for ≥2 additional treatments; adverse effects are minimal; the microbiome showed no stable resistance after several treatments

Treatment of IBS with constipation (IBS-C): surfactants such as docusate (Colace), lactulose, polyethylene glycol solutions, and milk of magnesia are effective; newer treatments, eg, lubiprostone, are costly and should not be used in patients suspected of having intestinal obstruction; adverse effects of newer agents include diarrhea, abdominal pain, dehydration, dizziness, headache, and nausea

Newer medications for IBS-C: lubiprostone, a locally acting chloride channel activator, increases water secretion to combat constipation; it is indicated for IBS-C in women >18 y of age; most common adverse effects are nausea and diarrhea; linaclotide is a guanylate cyclase antagonist that increases water secretion to combat constipation; 2 randomized studies showed modest benefit of improved abdominal pain; diarrhea causing discontinuation of medication is rare; plecanatide is another guanylate cyclase antagonist that also increases water secretion and promotes bowel transit; prucalopride is a highly selective 5-HT₄ receptor agonist; tegaserod, a nonselective 5-HT₄ receptor agonist, was withdrawn from the market because of cardiac dysrhythmias; prucalopride has not been associated with any adverse cardiovascular events as reported by Tack et al (2012); it promotes secretions and GI motility but has an additional warning for suicidal ideation or behavior

Complementary and alternative medicine:≥1 complementary medicine is used by 30% to 50% of patients with IBS; in a meta-analysis Billings et al (2021) showed that herbal and mind-body therapies are beneficial for abdominal pain; quality of studies is low and further studies are warranted; better integration of traditional and complementary medicine choices is needed; as of 2021 no studies have reported benefit of using cannabis

Pain control in IBS: medications include antispasmodic agents, tricyclic antidepressants (TCAs), and selective serotonin reuptake inhibitors (SSRIs); narcotic drugs should not be used in IBS; antispasmodic and antidepressant agents relax muscles; adverse effects include dry mouth, blurred vision, and dizziness; the mechanism of action of antidepressants is poorly understood; they increase visceral sensitivity, pain sensation, and can improve mood even in low doses; use of antidepressants in IBS is off-label; they take ≥3 weeks to be effective and are prescribed at lower doses than used for general depression; adverse effects are more common with TCAs than with SSRIs and include dry mouth, insomnia, constipation, palpitations, flushing, and decreased appetite; adverse effects of TCAs like drowsiness, anorexia, or weight loss might benefit some patients; SSRIs have a prokinetic effect that may be useful in IBS-C

Psychological therapy: includes cognitive behavioral therapy (CBT), hypnotherapy, and relaxation therapy; the strength of this recommendation is substantial as reported by Ford et al (2019) but there was significant heterogeneity among studies; newer therapies include contingency management therapy (patients are reinforced for positive behavioral change), self-administered CBT, meditation, and gut-directed hypnotherapy; no single psychological therapy has been shown to be most effective

Readings

Billings W et al. Potential benefit with complementary and alternative medicine in irritable bowel syndrome: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2021;19(8):1538-1553.e14. doi:10.1016/j.cgh.2020.09.035; Coëffier M et al. Intestinal permeability in patients with diarrhea-predominant irritable bowel syndrome: is there a place for glutamine supplementation? Gastroenterology. 2015;148(5):1079-1080. doi:10.1053/j.gastro.2015.02.057; Doron S and Snydman DR. Risk and safety of probiotics. Clin Infect Dis. 2015; 60 Suppl 2(Suppl 2):S129-S134. doi:10.1093/cid/civ085; Ford AC et al. American College of Gastroenterology monograph on management of irritable bowel syndrome. Am J Gastroenterol. 2018;113(Suppl 2):1-18. doi:10.1038/s41395-018-0084-x; Ford AC et al. Systematic review with meta-analysis: the efficacy of prebiotics, probiotics, synbiotics and antibiotics in irritable bowel syndrome. Aliment Pharmacol Ther. 2018;48(10):1044-1060. doi:10.1111/apt.15001; Ford AC et al. Effect of antidepressants and psychological therapies in irritable bowel syndrome: an updated systematic review and meta-analysis. Am J Gastroenterol. 2019;114(1):21-39. doi:10.1038/s41395-018-0222-5; Lembo A et al. Repeat treatment with rifaximin is safe and effective in patients with diarrhea-predominant irritable bowel syndrome. Gastroenterology. 2016;151(6):1113-1121. doi:10.1053/j.gastro.2016.08.003; Sahi N et al. Loperamide. StatPearls Publishing. 2021 Aug 3; Tack J et al. Systematic review: cardiovascular safety profile of 5-HT(4) agonists developed for gastrointestinal disorders. Aliment Pharmacol Ther. 2012;35(7):745-767. doi:10.1111/j.1365–2036.2012.05011.x.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Buch presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Buch was recorded exclusively for Audio Digest. Audio Digest thanks the speakers and the Texas Society for Gastroenterology and Endoscopy for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE352101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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