IBS Treatment Options

IBS treatment begins with your doctor explaining that IBS is not life threatening and does not lead to more serious forms of illnesses such as cancer or Inflammatory Bowel Disease. Treatment is based on addressing the most troublesome symptom and severity.

There is limited research data on lifestyle changes that may improve IBS symptoms such as exercise or stress reduction.

Adding fiber to your diet has shown only marginal improvement in IBS. Any benefits related to fiber and IBS symptoms may be found in soluble fiber, such as psyllium and not insoluble fiber, such as bran. Bran seems to exacerbate symptoms of abdominal distention and gas.

Recent research surrounding diet and IBS has shown great improvement in symptoms in some individuals utilizing a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. The low FODMAP diet is not a diet of exclusion. Rather, it is a diet best managed by a Registered Dietitian, which restricts and re-introduces foods in a controlled manner which are generally associated with intestinal fermentation. The reduction in fermentation yields less bloating and gas which leads to significant symptoms improvement for some IBS patients.

There has been a plethora of medication treament options for IBS in the last several years. Medication treatments focus on the primary symptom which causes a patient to seek help from a doctor, ie: diarrhea (IBS-D), constipation (IBS-C) and/or abdominal pain. While there are medicines which target IBS, there is also a significant placebo response rate, up to 70%, to all treatments in patients with IBS.

Symptoms Therapy Treatment
Diarrhea Opiod agonist Eluxadoline (Viberzi), Loperamide (imodium)
  Diet Low FODMAP, gluten free
  Bile salt sequestrants Cholestyramine (Questran) / Colestipol (Colestid)
  Probiotics (Bifidobacterium infantis 35624) Align, VSL#3, Visbiome
  Antibiotics Rifaximin (Xifaxan)
  *5-HT3 antagonists Alosetron (Lotronex), Ondansetron (Kytril), Ramosetron (IBset)
  Serum-derived bovine immunoglobulin/protein isolate EnteraGam
Constipation Psyllium Metamucil
  PEG (polyethylene glycol) Miralax, Glycolax
  *Chorine channel activator Lubiprostone (Amitiza)
  *Guanylate Cyclase C agonists Linaclotide (Linzess / Constella)
  *5-HT4 receptor agonist Prucalopride (Resotran)
Abdominal Pain Antispasmodics Dicyclomine (Bentyl/Bentylol)
  Peppermint oil Colpermin
  **Tricyclic antidepressants Amitriptyline (Elavil), Desipramine (Norpramin / Pertofrane)
  ***SSRI antidepressants Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa)

* also provides abdominal pain relief
** may also provide diarrhea relief
*** may also provide constipation relief

Psychological and behavioral therapy may help IBS patients control and reduce pain and discomfort usually in conjunction to medical treatments. Therapy includes cognitive behavioral therapy (CBT), hypnosis, exposure and various relaxation methods to reduce muscle tension, hypervisceral sensitivity and catastrophic beliefs to GI symptoms. A large number of research studies in IBS confirm the values of these treatments.

Future Directions in Treatment

There are several investigational medications being studied for IBS. Medications focus on different aspects in the path to IBS symptoms, ie: abdominal pain, bowel motility or absorption of elements in the bowel itself. Some existing medications are already in use off-label for IBS, e.g. low doses of antidepressants for pain and diarrhea or constipation predominant IBS. The complex interaction among factors such as a disturbance in the gut bacteria, altered immune function of the gut lining, altered gut signalling (visceral hypersensitivity) and central nervous system dysregulation of the gut signalling and gut function makes it difficult to develop a single medication that will treat all types of IBS. That being said, there are several clinical research studies during the development of new medications which may be of interest to IBS patients.

Fecal Microbiota Transplantation (FMT) background

Fecal Microbiota Transplantation (FMT) is a new treatment that has been shown to be over 90% effective for treating C. difficile infection in patients who had previously failed to recover with antibiotic therapy. During FMT, a fecal preparation from a carefully screened, healthy stool donor is transplanted into the colon of the patient. There are multiple routes of administration (e.g., via colonoscopy, naso-enteric tube, capsules), each of which has unique risks and benefits.

Though the mechanism has yet to be determined, it is believed that FMT works by repopulating the patient’s microbiome with diverse microorganisms that competitively exclude C. difficile

In a healthy gut community, C. difficile is out-competed by many different bacterial species. However, receiving antibiotic treatment disrupts this ecosystem by killing those protective bacteria. C. difficile forms spores that are resistant to antibiotics. No longer outcompeted, this pathogen establishes itself in the gut and produces toxins that leave patients suffering from severe diarrhea, abdominal pain, and, often, fever. With an infusion of bacteria from a healthy donor's stool, the C. difficile is again out-competed.  

Researchers are also exploring FMT's potential role for treating other gastrointestinal diseases, such as IBS and Crohn's Disease. A small study (16 patients) was reported at Digestive Disease Week (DDW) 2017  with some limited positive results with FMT and IBS.

Although FMT is a powerful tool for treating C. difficile infection, there are also important risks. Stool is a complex living mixture of bacteria and other organisms. While stool donors can be carefully screened for known infectious agents, there is always a risk that the tests might fail to detect a pathogen. There are also procedural risks associated with receiving an FMT by colonoscopy or other methods of administration.

Source(s):

Gastroenterology 2016;150:1393–1407
The Microbiome Health Research Institute, d.b.a. OpenBiome