How IBS Is Treated

Irritable bowel syndrome (IBS) treatment does not readily fit into a "one-size-fits-all" plan. Working with your doctor and a little trial and error can help you find your own regimen for managing symptoms. This will likely require a multi-faceted approach, which might include prescription or over-the-counter medication, dietary changes, and psychotherapy.

The IBS treatment process tends to vary greatly from region to region and even doctor to doctor. To help guide and standardize this process, the American College of Gastroenterologists in 2021 put out new clinical guidelines. Whether you're newly diagnosed or looking for treatments to add to your management plan, they may help you and your doctor decide on your next step.

If you haven't already done so, it is essential that you see a doctor to discuss any ongoing digestive symptoms you may be having—even if you've been diagnosed with IBS and are following a recommended treatment plan to the letter. In the event your condition has changed, your treatment approach must evolve as well.

Diet

The simple act of eating—and eating large or fatty meals, in particular—can stimulate bowel contractions. Because of that, changing your eating habits is one of the most common ways to manage IBS.

Diet Restriction

A food diary can help you track what you eat and how it makes you feel. If you notice your symptoms tend to flare after eating a certain food, consider eliminating that food (and similar ones) for a period of about three months to see if this has any effect on your IBS. If not, try eating the food again and repeat the process with the next food on your list.

Common food and drink culprits include:

• Fatty foods
• Gas-producing vegetables
• Artificial sweeteners
• Alcohol

Note, however, that what affects your IBS can be somewhat unpredictable. Stress and hormonal changes also contribute to IBS symptoms. Because of this, a food you tolerate poorly on one occasion may be just fine on another.

You may also consider an elimination diet to rule out gluten sensitivity, lactose intolerance, or fructose malabsorption.

The Low-FODMAP Diet

FODMAP stands for fermentable oligosaccarides, disaccarides, monosaccharides, and polyols. These carbohydrates don't absorb well into your digestive system. Research suggests they can be particularly problematic for people with IBS because they can compound your issues with gas, bloating, abdominal pain, diarrhea, and/or constipation.

Following a low-FODMAP diet can be challenging, but it has some sound research support for its effectiveness and the ACG's 2021 guidelines recommend trying it. The diet involves eliminating FODMAPS from your diet for six to eight weeks and then gradually adding them back to see how well you tolerate them.

Fiber

Increasing your fiber intake is generally recommended for IBS due to its many health benefits and its ability to make your stool a better consistency. However, it is best to add fiber slowly to allow your body time to adjust. Evidence suggests that people with IBS benefit more from soluble fiber than from insoluble fiber and it's strong enough to receive backing from the ACG.

Meal Size and Timing

To ease the stress on your digestive system, it's recommended that you eat smaller, more frequent meals instead of the traditional three big ones per day. One possible exception is that for constipation, a large breakfast may help encourage intestinal contractions and the urge to have a bowel movement.

Over-the-Counter (OTC) Therapies

You have a wide variety of OTCs to choose from for digestive symptoms. While you can get these without a prescription, it's best to check with your doctor before using any OTC product for IBS.

A few of the more commonly used OTC drug options include:

• Imodium: Helpful for easing diarrhea, but not necessarily IBS pain
• Laxatives: Can alleviate constipation; brands include Metamucil, Benefiber, and Citrucel
• Probiotic supplements: Balance gut flora by providing "friendly bacteria"

The ACG recommends against probiotics, however, saying that studies so far have been too small and inconsistent to prove any benefits.

Prescriptions

Traditionally, medication options for IBS have been limited. Luckily, that situation is changing rapidly as new medications are developed. Some are created specifically for IBS while others are meant for different conditions but can help alleviate IBS symptoms.

IBS-Specific Medications

Several new IBS drugs have come onto the market. They typically work on receptors within the large intestine to bring about IBS symptom relief. Receptors are parts of cells that other substances can communicate with in order to change the cell's behavior.

IBS-C

Options for the treatment of constipation-predominant IBS (IBS-C) include:

• Amitiza (lubiprostone)
• Linzess, Constella (linaclotide)
• Trulance (plecanatide)
• Motegrity (prucalopride)
• Zelnorm (tegaserod)

Of these, the ACG recommends lubiprostone, linaclotide, and plecantide. It recommends tegaserod in women under 65 with no cardiovascular risk factors who haven't responded to other treatments. The 2021 guidelines don't mention prucalopride.

IBS-D

So far, only one medication has come on the market for diarrhea-predominant IBS (IBS-D): Viberzi (eluxadoline). This medication is recommended by the ACG.

Antibiotics

People are often surprised when they hear that antibiotics may be prescribed for IBS, as taking a round of antibiotics can often make IBS symptoms worse. However, the specific antibiotics used to treat IBS are not absorbed in your stomach. Rather, they target bacteria in your small and large intestine.

Of this class, only Xifaxan (rifaximin)—used for the treatment of non-constipation IBS—has Food and Drug Administration (FDA) approval and is recommended by the ACG for IBS-D.

Antidepressants

Antidepressant medications can affect how your digestive system functions and can also alleviate some types of pain, including the visceral pain of IBS. They also can safely be taken for a long period of time—which is an definite advantage when you have a chronic disorder like IBS.

Tricyclic antidepressants are the most often used antidepressants to treat IBS and the ones favored by the ACG. They include:

• Amitriptyline
• Doxepin
• Norprimin (desipramine)
• Surmontil (trimipramine)

Doctors are more likely to recommend an antidepressant if your symptoms have not been addressed through lifestyle and dietary modifications, and if you also experience depression and/or anxiety alongside your IBS. In those cases, your gastroenterologist may work closely with psychiatrist.

Another type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) is prescribed less often for IBS. This class includes:

• Celexa (citalopram)
• Lexapro (escitalopram)
• Paxil (paroxetine)
• Prozac, Sarafem (fluoxetine)
• Zoloft (sertraline)

Antispasmodics

Antispasmodics are the most frequently prescribed medications for IBS as they're believed to help to ease symptoms of abdominal pain and cramping, particularly for people who have IBS-D.

However, the ACG guidelines recommend against their use, stating that the only studies are outdated and of poor quality, and that side effects are common.

Examples of antispasmodics that may be prescribed for IBS include:

• Bentyl (dicyclomine)
• Levsin (hyoscyamine)

Antispasmodics work best if taken 30 to 60 minutes prior to eating and may be better at providing short-term, as opposed to long-term, relief of symptoms.

Psychological Therapies

A variety of psychological therapies have been studied for their effectiveness in reducing the frequency, intensity, and duration of IBS symptoms, including cognitive behavioral therapy (CBT), hypnotherapy, stress management, and relaxation exercises.

Of these, CBT and gut-directed hypnotherapy have the most solid research supporting their effectiveness in reducing IBS symptoms and both are recommended by the ACG.

CBT is a form of psychotherapy in which you are taught strategies for modifying maladaptive thinking patterns, as well as new behaviors for managing anxiety and handling stressful situations.

Hypnotherapy involves getting into a relaxing and comfortable state of consciousness in which specific suggestions are offered in order to lead to a permanent change in behavior.

The recommendation of these treatments doesn't imply that IBS is a psychological illness. Rather, they're a way to build coping skills and better habits so you can handle your IBS long-term without the risk of possible negative side effects of medication.

Peppermint Oil

Studies have shown that enteric-coated peppermint oil has strong antispasmodic qualities and, thus, may be effective in easing IBS pain. The ACG gives it a conditional recommendation for abdominal pain and overall symptoms based on what it calls low-quality evidence.

However, a 2019 review of evidence found it be quite promising, while also a generally safe and well-tolerated treatment. Among the qualities that make peppermint relevant for treating IBS, it's an:

• Anti-inflammatory
• Anesthetic
• Antioxidant
• Antimicrobial
• Immunomodulant

The enteric coating is an important part of taking peppermint oil. "Enteric" means it's broken down in the intestines, not the stomach, where the peppermint can cause heartburn.

Treatments Not Recommended for IBS

In addition to antispasmotics, probiotics, and PEG, the ACG guidelines recommend against these IBS treatments:

• Bile acid sequestrants for IBS-D
• Fecal transplant

The negative recommendations were based on low evidence and/or inconsistent studies that have failed to establish effectiveness or proper dosages/procedures. None of these treatments is considered harmful.