Irritable Bowel Syndrome

Fiber/laxatives

Psyllium or other soluble fiber

Polyethylene glycol

Pitfalls

1.

Nonsoluble fiber and polyethylene glycol can worsen bloating, gas, and cramping.
2.

Wheat bran should be avoided.
3.

Require self-titration and adjustment if diarrhea occurs.
4.

May not improve pain of IBS.
5.

Cost of over-the-counter medication not covered by insurance.

15.6.2 Over-the-Counter Antidiarrheal Medications

Loperamide is the first-line agent in management of diarrhea in IBS. Other antidiarrheal medications are not currently recommended for IBS. Loperamide works in multiple mechanisms including inhibition of peristalsis, prolonging gut transit, and reduction of fecal volume [3].

Pitfalls

1.

Can lead to constipation
2.

May not improve pain and global symptoms of IBS
3.

Cost of over-the-counter medication not covered by insurance

15.6.3 Antispasmodics

Antispasmodics are used as needed or prophylactically preprandial to control abdominal pain, diarrhea, bloating, and urgency. This is achieved through smooth muscle relaxation.

Antispasmodics
Hyoscyamine
Dicyclomine
Methscopolamine

Pitfalls

1.

Can worsen constipation dominant disease
2.

Caution with anticholinergic side effects (fatigue, dry mouth, dizziness)
3.

Caution with sedation
4.

Caution use in elderly and cognitively impaired

15.6.4 Prosecretory Agents

Two agents are currently FDA approved for IBS-C patients. Lubiprostone is a chloride channel activation increasing intestinal fluid secretion. Linaclotide is a novel agent that reduces activation of visceral pain fibers.

FDA approved prosecretory agents

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