Irritable Bowel Syndrome


Diagnosis

Differential Diagnoses

Treatment

  1. Reassurance, work on coping strategies, exercise
  2. Identify dietary and psychosocial triggers
  3. Fiber supplementation: bran, psyllium, methylcellulose
  4. Antispasmotics: prophylactic before meals or for acute pain
  5. Imodium or lomotil for diarrhea
  6. SSRIs or TCAs

Disposition

  1. Young, non-toxic, palpable sigmoid: outpt therapeutic trial
  2. Older pts should probably be admitted to R/O colonic neoplasm w/colonoscopy or barium enema
  3. This disorder best handled by outpt GI specialist who can build up long term relationship w/pt

Treatment Summary

Constipation-Predominant Diarrhea-Predominant Alternating
W/O pain & bloating W/ Pain & Bloating W/O Pain & Bloating W/ Pain & Bloating W/O Pain & Bloating W/ Pain & Bloating
Psyllium : (2.4 g of soluble dietary fiber per dose) one dose orally in a glass of water, up to three times daily

Lactulose
: 10-20 g (or 15-30 mL) orally once daily, can increase to twice daily or three times daily if no response, Max: 40 g/day (or 60 mL/day)

Amitiza (Iubipostone): 24 micrograms orally twice daily

Linzess (linaclotide) : 290 micrograms orally once daily

Psyllium
Lactulose

GoLytely

Anti-Spasmodic:

Dicyclomine : 10-20 mg orally four times daily when required

Levsin (Hyoscymine) : 0.125 to 0.25 mg orally/sublingually three to four times daily when required, maximum 1.5 mg/day.
Peppermint oil (Mentha x piperita) : one dose (0.2 mL of peppermint oil) orally three times daily; consult product literature for further guidance on dose

SSRI:
Paroxetine : 20-40 mg orally once daily
Citalopram
: 20-40 mg orally once daily
--
Linzess
(linaclotide) :

Anti-Diarrheals:
Loperamide
: 2-4 mg orally initially, followed by 2 mg after each loose stool when required, maximum 16 mg/day
Cholestyramine : 2-4 g orally two to four times daily
Lotronex (alosetron) : 0.5 to 1 mg orally twice daily
Psyllium
Lactulose

GoLytely

Loperamide

Anti-Spasmodic:
Dicyclomine
Levsin (Hyoscymine)
Peppermint oil (Mentha x piperita)

Psyllium
Lactulose

GoLytely (polyethylene glycol/electrolytes)

Loperamide

TCA anti-depressants:
Desipramine
: 10-25 mg orally once daily at bedtime
Amitriptyline : 10-25 mg orally once daily at bedtime
Doxepin : 25-75 mg orally once daily at bedtime

SSRI:
Paroxetine : 20-40 mg orally once daily
Citalopram : 20-40 mg orally once daily
  Rifaximin : 550 mg orally three times daily for 14 days

Anti-Spasmodic:
Dicyclomine :
Levsin (Hyoscymine) :
Peppermint oil (Mentha x piperita) :

TCA anti-depressants:
Desipramine
: 10-25 mg orally once daily at bedtime
Amitriptyline : 10-25 mg orally once daily at bedtime
Doxepin : 25-75 mg orally once daily at bedtime

  • Amitiza (Iubipostone)
    • Chronic consitpation: 24 mcg PO bid
    • Opioid-induced constipation: 24 mcg PO bid
    • IBS, Constipation predominant: 8 mcg PO bid
  • Levsin (Hyoscymine) [SL, SC, IM, IV]
    • GI tract spasm: 0.125-0.25 mg PO/SL q4h prn
    • Bladder spams: 0.125-0.25 mg PO/SL q4h prn
    • IBS, adjunct tx: 0.125-0.25 mg PO/SL q4h prn
    • PUD, adjunct tx: 0.125-0.25 mg PO/SL q4h prn
  • Dicyclomine [10,20]
    • 20-40 mg PO qid
  • Donnatal (phenobarbital/hyoscyamine/atropine/scopolamine)
    • IBS: 1-2 tabs PO q6-8h
    • Acute enterocolitis: 1-2 tabs PO q6-8h
    • Duodenal ulcer: 1-2 tabs PO q6-8h
  • Linzess (linaclotide) [145, 290 mcg]
    • IBS: 290 mcg PO qd
    • Chronic idiopathic consitpation: 145 mcg PO qd
  • Zelnorm (tegaserod)
    • WITHDRAWN FROM US MARKET 2007

 

ITE 2014 Q 21. Which one of the following medications used for anxiety has also been shown to reduce the symptoms of irritable bowel syndrome?

A) Buspirone
B) Clonazepam (Klonopin)
C) Divalproex sodium (Depakote)
D) Risperidone (Risperdal)
E) Citalopram (Celexa)

ANSWER: E

  • Irritable bowel syndrome (IBS) symptoms improve with several different medications and alternative therapies. Exercise, probiotics, antibiotics, antispasmodics, antidepressants, psychological treatments, and
    peppermint oil all have evidence that they may improve IBS symptoms (SOR B). A Cochrane review of 15 studies involving 922 patients found a beneficial effect from antidepressants with regard to improvement in pain and overall symptom scores compared to placebo. SSRIs used in these trials included citalopram, fluoxetine, and paroxetine, and tricyclic antidepressants included amitriptyline, desipramine, and imipramine. Buspirone, clonazepam, divalproex sodium, and risperidone have not been shown to be effective for symptom relief in IBS patients.

    Ref: Ruepert L, Quartero AO, de Wit NJ, et al: Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome. Cochrane Database Syst Rev 2011;(8):CD003460. 2) Wilkins T, Pepitone C, Alex B, Schade RR: Diagnosis and management of IBS in adults. Am Fam Physician 2012;86(5):419-426. 3) Ford AC, Talley NJ: Irritable bowel syndrome. BMJ 2012;345:e5836.