Things to do:
- First, check celiac disease serologies in patients with suspected IBS-D ( diarrhea predominant) or IBS-M ( mixed). Based on 36 studies,2.6 % of patients with IBS-D or IBS-M have celiac disease at the same time!
- In patients without alarm symptoms, if you suspect IBS-D or IBS-M, please check calprotectin/lactoferrin and CRP to rule out IBD! Do not use ESR-it`s not a sensitive test for it!
- It`s recommended to have a positive diagnostic strategy instead of using an exclusion strategy to start treatment. CBC, CRP, and celiac serology, combined with Rome IV criteria, are all you need to diagnose! Earlier diagnosis leads to earlier treatment!!
- Remember to categorize your patients using the Bristol stool form scale.
- In patients with constipation not responsive to treatment, evaluate for pelvic floor disorder( balloon expulsion test or anorectal manometry)
- Give a limited trial to FODMAP.
- Chloride channel activators are recommended to treat global IBS-C symptoms. Lubiprostone is a prostaglandin E1 analog that binds to Cl channels—approved for treating IBS-C-8 mcg BID.
- To treat IBS-C syndromes, it is recommended to use Guanylate cyclase activators to stimulate intestinal fluid secretions and peristalsis. Two FDA-approved medications are linaclotide ( 290 mcg daily) and plecanatide (3 mg daily).
- Serotonin agonists-Tegaserod is recommended for use for IBS-C for women <65 years old with one or fewer cardiovascular risk factors.
- Gut-directed psychotherapies are generally recommended (CBT and hypnotherapy)
- RIfaximn is recommended to treat IBS-D symptoms.
- Alosetron is recommended for IBS-D symptoms in women—potential side effects: severe constipation and bowel ischemia.
- Eluxadoline is a mixed mu/kappa opioid receptor agonist, and delta receptors antagonist is recommended for men and women for IBS-D. It cannot be used in patients with alcohol use disorder, chronic pancreatitis, sphincter Oddi dysfunction, suspected biliary obstruction, and post-cholecystectomy
- Tricyclic antidepressants are recommended for use in patients with global IBS symptoms.
Things to avoid:
- However, do not test for the enteric pathogen panel! For most patients, these infections resolve spontaneously and are not the cause of IBS.
- There is no need to perform a colonoscopy in patients with IBS under 45 years old without warning signs! Colorectal cancer is unlikely in a young patient without a family history and no alarming signs. And, routine colonoscopy does not reassure patients with IBS-they still will continue to have symptoms.
- Do not test for food allergies!
- It is not recommended to use antispasmodics for patients with IBS. PRN use is reasonable, but chronic use leads to tachyphylaxis
- Bile acid sequestrant are not recommended for IBS-D
- Probiotics are also not recommended for patients with IBS. The data are not convincing. According to a meta-analysis, single agents are not better than placebo, while combination agents are slightly better than placebo.
- PEG products are not recommended for use to relieve the symptoms of global IBS.
- A fecal transplant is not recommended.