L Chang. Gastroenterol 2021; 163: 1092-1098. How to Approach a Patient with Difficult-to-Treat IBS

For a short article, this review provides a lot of practical advice. Challenges with IBS include the lack of objective biomarkers and “patients are often dissatisfied with a positive diagnostic approach or even after multiple negative tests.” The author recommends the following:

• Confidently communicate the diagnosis of IBS
• Explain visceral hypersensitivity and its associated with pain, and bloating and why central neuromodulators and behavioral therapy are often used. Explain that IBS can be associated with high-amplitude propagating contractures which can cause pain/diarrhea
• Treatment focused on ‘RESET’ =Relationship with patient-provider, Education/reassurance, Symptom assessment, Exacerbating/alleviating factors, and Targeting treatment (see Table 1)

Treatment may need to target gut, brain and/or both

• Dietary treatments considered 1st line approach
• Treatment pharmacology options for IBS-D include antidiarrheals, antispasmotics, rifaximin, eluxadoline, alosetron (rarely, can cause ischemic colitis), bile acid sequestrants
• Treatment pharmacology options for IBS-C include polyethylene glycol, lubiprostone, linaclotide, plecanatide, and tegaserod (restricted to women <65 yrs w/o cardiovascular dz)
• Treatment pharmacology options for all IBS include TCAs (start with low dose and can titrate upwards; amitriptyline for IBS-C, nortriptyline or desipramine for IBS-M or IBS-C), SNRI (eg. duloxetine (may be better than TCAs in patients with IBS-C and comorbidities like fibromyalgia and depression), mirtazapine (small studies demonstrated benefit for IBS-D and functional dyspepsia), SSRIs (“consider…in patients with predominant anxiety and/or depression…advise against its use as primary treatment for IBS w/o comorbid psychological disorder”), delta ligand agent (eg. pregabalin) (consider if refractory to other treatments), and brain-gut therapies (eg. CBT, GDH)

Related blog posts:

• Patient Information on Irritable Bowel (Rome Foundation)
• Mechanisms of IBS and Functional Pain (2021)
• Is There a Way to Prove Which Dietary Factors Trigger IBS?
• Advice on Abdominal Pain for Everyone Who Cares for Children | gutsandgrowth
• Brave New World: Psychotropic Medications and Pediatric Functional GI Disorders
• NY Times: “Millions Take Gabapentin for Pain. But There’s Scant Evidence It Works.” | gutsandgrowth
• A 6-Year Study of Amitriptyline, Escitalopram, and Functional Dyspepsia
• Advice on Abdominal Pain for Everyone Who Cares for Children | gutsandgrowth
• Does buspirone help functional dyspepsia?
• How Effective are the Treatments for Functional Abdominal Pain? | gutsandgrowth
• Will I Have This Stomach Pain Forever? (Part 1) | gutsandgrowth
• FODMAP diet -Real World Experience
• Pregabalin Helpful for Functional Dyspepsia (Small Study)

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