How to meet the challenges of managing patients with IBS

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doi:doi: 10.12788/jfp.0299

Applied Evidence

How to meet the challenges of managing patients with IBS

J Fam Pract. 2021 November;70(9):431-441 | doi: 10.12788/jfp.0299

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References

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Serotonergic agents. Serotonin (5-hydroxytryptamine [5-HT]) modulates gastrointestinal secretions, gut motility, and visceral sensation. Researchers have developed IBS treatments that target receptors involved in these functions.

Tegaserod is a partial, selective 5-HT₄ agonist indicated for the treatment of IBS-C in women. A study with 661 women with IBS-M and IBS-C showed that tegaserod increased the number of bowel movement episodes. Patients also reported higher stool consistency scores and fewer days with straining compared to placebo.²⁷ The medication was removed from the market in 2007 because of its potential for cardiovascular adverse effects³; however, it was reintroduced in 2019 for women < 65 years of age with IBS-C. Consider prescribing tegaserod if other treatment options fail to alleviate symptoms.

Treatment of IBS-D

Antibiotics. The nonabsorbable antibiotic rifaximin is approved by the FDA for IBS-D at a dosage of 550 mg tid for 2 weeks.¹ Several studies show improvement in IBS global symptoms with the recommended treatment course^51-53; benefit persisted for the 10-week follow-up study period.¹ A meta-analysis found that the NNT for rifaximin is 8-11.⁵⁴Preliminary data indicate that the rates of Clostridioides difficile infection and microbial resistance among rifaximin users are low.³ Consider using rifaximin as a first-line treatment option for patients with IBS-D. Retreatment might be necessary because the drug’s effect gradually disappears.⁹

Antidiarrheals. Eluxadoline is a µ-opioid and κ-opioid receptor agonist and δ-opioid receptor antagonist with effects on the intestinal nervous system.³ Several meta-analyses demonstrated that eluxadoline improves abdominal pain scores and daily stool consistency in IBS-D patients.^53,54 Eluxadoline should be considered early in the management of IBS-D patients. The most common adverse effect is constipation.

The FDA issued a safety warning in 2017 regarding an increased risk of pancreatitis in patients taking eluxadoline who do not have a gallbladder. In addition, eluxadoline should be avoided in patients with a history of sphincter of Oddi dysfunction, alcohol abuse, or severe liver problems.^3,54

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