IBS Medications: Should They Be A Part Of Your Treatment Plan?
If you have had IBS for one month, one year or 20 years, you have probably encountered a situation such as this:
You have run the gamut of tests, blood work, scans, scopes, etc. and you now sit in your doctor’s office listening to him/her tell you that you have irritable bowel syndrome (either constipation predominant, diarrhea predominant or mixed). The likely response to what to do about this may go something like “eat more fiber, follow the low FODMAP diet, take MiraLAX every day, or here is a medication to help stop or slow your diarrhea.” Then out the door you go!
In short, patients typically leave feeling under-educated about their condition. They often are recommended medications (either over the counter or prescription) as a first-line defense in managing their condition.
Research shows that 10-15% of the population is affected by IBS, where 35% of these people report their symptoms to be moderate, and 25% report their symptoms to be severe. These 35% and 25% are typically the ones who receive recommendations for medications. That means >50% of those with IBS likely take some form of medication (either over the counter or prescription).
If you didn’t already know, the world of IBS medications is complicated! These medications are not one size fits all. They have different mechanisms of action, different potencies, and side effects. Some are only taken as needed, and others are taken regularly. All of this should be considered and discussed with your healthcare team before adding one of these medications to your treatment plan.
At Gutivate, we regularly encounter clients who use medications as part of their symptom management regimen. We believe that medications can be an incredibly helpful tool for many people. We also believe that every patient’s treatment plan should be personalized to them and that IBS is best addressed from a holistic perspective where all aspects of a patient’s life are attended to and adjusted to best support their gut. It’s important to have an educated perspective about the multitude of medications out there so that if you choose to include medication in your IBS tool kit, you are prepared to make an informed decision.
Below, I am going to delve into the world of IBS medications to help give you a better understanding of these potential tools for your symptom management.
IBS-C Medications
Medications for IBS-C work to either soften hard stools or increase gut motility to help push stool out. There are over-the-counter medications as well as prescription-only medications. Some common medications recommended for this population include:
Over the Counter:
Fiber Supplements: Many providers will recommend an increase in fiber (through food or supplement form) to help relieve their patient’s constipation.
Possible Issues: Increases in fiber through food or supplement form can cause an increase in gas and bloating at first as your gut gets used to the increased fiber load. Without proper education, these side effects may cause a patient to stop using the fiber prematurely. Water intake must also be increased at the same time. Inadequate hydration can cause the opposite effect to occur, increasing constipation. Lastly, there are LOTS of different fiber supplements out there, and without proper education, a patient may feel unequipped to pick the supplement best suited for his/her needs.
Laxatives: Laxatives are medications that help stimulate or facilitate a bowel movement. There are different categories of laxatives, each with a different mechanism of action. The two most common are osmotic laxatives and stimulant laxatives. Osmotic laxatives, sometimes called stool softeners, work by gently drawing water into the colon through a process called osmosis. This increase in water increases stool volume and causes the bowel wall to stretch. This triggers your digestive system to initiate a bowel movement in a gentle and more natural manner. On the other hand, stimulant laxatives work by causing the intestinal muscles to contract more, helping to push out a bowel movement.
Stool Softeners/Osmotic Laxatives: Colace, Senna, Miralax
Stimulant Laxatives: Dulcolax, Senokot
Possible issues that come with using any form of laxative is that the increase in water being drawn into the colon can lead to bloating and, if used at too high of a dose, can make stool very mushy and/or cause diarrhea.... not what we are looking for! Stimulant laxatives also have the potential for abuse where your gut can actually become dependent on the medication to have a bowel movement.
Prescription
These medications are known as pro-motility agents as they work to increase gut motility. There are a few ways these medications achieve this result. These different mechanisms of action are important to consider as you try to decide if a medication is right for you. Commonly prescribed promotility agents are listed below.
Linaclotide (Linzess): This type of medication is also known as a guanylate cyclase-C agonist. The active ingredient, linaclotide, increases cyclic guanosine monophosphate (cGMP) levels within the cells of a person’s gut. Studies show this increase in cGMP reduces intestinal pain and accelerates gut motility.
Lubiprostone (Amitiza): This medication is only FDA-approved for women at least 18 years old. This medication increases fluid secretion in your intestines, thereby accelerating the movement of stool through your intestines
Tegaserod (Zelnorm): this medication is only FDA-approved for women under 65. This medication is termed a “5-HT4 serotonin agonist.” It increases the amount of serotonin in the gut, which results in increased peristalsis and a reduced sensory response (increased gut motility and decreased pain).
Prucalopride (Motegirty): Motegrity is also a “5-HT4 agonist” and increases the amount of serotonin in the gut. So, the mechanism of action is the same, but side effects differ. So, this would be a situation to evaluate the side effects of each medication side by side to help you make an informed decision.
Plecanatide (Trulance): This medication, like Linzess, is known as a guanylate cyclase-C agonist and works to build up the levels of cGMP, thereby accelerating gut motility and decreasing pain.
The main issue with these medications is that they can cause diarrhea, especially if the dose is too high. Communicating regularly with your GI doctor about how the medication is affecting you is important so that the correct dose can be tailored to fit your needs. It is also important for your healthcare provider to make sure you don’t have a bowel obstruction/blockage before starting you on any of these medications. Only start one of these medications once your provider has given you the green light.
IBS-D Medications
Medications for IBS-D focus on lowering the amount and frequency of loose stools you experience. These include both over-the-counter (OTC) and prescription medications.
OTC Medications
Fiber Supplement: Many providers will recommend an increase in fiber, specifically soluble fiber, to help bulk up a patient’s stool. Psyllium and banana flakes are most often recommended in these situations.
Anti-diarrheal medications: Some providers may recommend medications like loperamide (Imodium A-D) to help control diarrhea.
Possible issues arise here if the patient is not properly educated on the timing and dosage of the loperamide (Imodium). This medication is best used as needed, not regularly, and is best used as a short-term treatment versus long-term treatment. Its purpose is to slow or stop diarrhea, so it can lead to constipation. Excessive use of this med can create a constipation/ diarrhea cycle for the patient.
Prescription Medications
Eluxadoline (Viberzi): Eluxadoline contains mixed opioid receptors which work to reduce GI muscle contractions and fluid secretion in the intestines.
Alosetron (Lotronex): This medication is also designed to relax the colon and slow the movement of waste through the colon works by blocking the action of serotonin on the intestinal system.
Alosetron can be prescribed only by doctors enrolled in a special program. It is intended for women only who have severe cases of IBS-D and who haven’t responded to other treatments. This medication can have rare but significant side effects, so these should be discussed thoroughly before deciding to add it to a treatment plan.
Rifaximin (Xifaxan): This antibiotic (which is frequently used to treat SIBO) has been shown to decrease bacterial overgrowth as well as diarrhea. It is intended for short-term use only, typically only taken 14 days at a time.
Tricyclic antidepressants: This type of medication (whose main intent is to relieve depression) has been shown to also help reduce pain. If you have diarrhea and abdominal pain without depression, your doctor may suggest a lower-than-normal dose of one of these medications.
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Below are two additional categories of prescription medications prescribed for IBS-D, although they are currently recommended against by the American College of Gastroenterology.
Bile Acid Binders: Cholestyramine (Prevalite), Colestipol (Colestid) or Colesevelam (Welchol). Bile acid binders can cause bloating and are better suited for those who have a condition called Bile Acid Diarrhea. These two conditions mirror each other in symptom presentation but are different diagnoses altogether. This highlights another reason why it is important to have knowledgeable clinicians on your healthcare team as you navigate this world of medications.
Antispasmodics: Even though the ACG recommends against these drugs, they are commonly prescribed for IBS-D. They seem to relieve the abdominal pain and cramping typically associated with this condition. Research regarding the safety of antispasmodics for long-term use is limited, so these medications are more appropriate for short-term use. Common antispasmodics include:
Bentyl (dicyclomine)
Buscopan (hyoscine butylbromide)
Anaspaz, Cystospaz, Levbid, Levsin (hyoscyamine)
Since these medications are meant to help relieve diarrhea, they can also make you constipated. This side effect is noted to be severe for alosetron and eluxadoline. If you start to take any of these medications and begin to experience constipation, contact your doctor immediately to discuss this with them.
Possible Future Drugs
There are two new medications on the block that are currently going through safety trials and could eventually be used to treat IBS:
Asimadoline: Going through clinical trials for treating IBS-D
Elobixibat: Under investigation for the treatment of chronic idiopathic constipation (CIC)
Are there ways to treat IBS without medications?
As mentioned earlier, at Gutivate, we believe that every patient’s symptom management plan should be personalized to them and that IBS is best addressed from a holistic, multidisciplinary perspective where all aspects of a patient’s life are attended to and adjusted to best support their gut. We believe dietary and lifestyle interventions are the best first-line defenses in combating IBS followed by medication intervention if symptoms persist. Hopefully, your healthcare provider will suggest non-medicinal treatments for you as well before suggesting medications.
When it comes to dietary and lifestyle interventions, The American College of Gastroenterology supports both the 3-phase low FODMAP diet as well as adequate fiber intake (25-35 grams/day) as important non-pharmacological treatment strategies for IBS symptom management. Working with a Registered Dietitian to address these first-line defenses will help you find success as you implement these necessary steps. Dietitians help personalize recommendations to fit your individual needs and preferences so new habits are more likely to stick. They can also be an advocate for you and help strengthen communication between your healthcare team.
Additional IBS management strategies could include pelvic floor physical therapy, cognitive behavioral therapy, relaxation techniques and/or gut-directed hypnotherapy. Again, IBS is not a one size fits all diagnosis and there is no one size fits all treatment plan. Working together with your healthcare team and advocating for your needs and preferences is the best way to craft an IBS tool kit individualized to you, your symptoms and your life.
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Source: https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-treatment/drc-20360064
Source: https://www.goodrx.com/conditions/irritable-bowel-syndrome/medications-for-ibs
Source: https://www.verywellhealth.com/ibs-medication-4014169
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