Keys to IBS care: Understanding medical options, where they ‘might be most effective’
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Results from a 2023 nationwide survey published in Gastroenterology estimated the prevalence of Rome IV irritable bowel syndrome in the U.S. climbing to 6.1% — higher than previous reports of 4.7% to 5.3%.
On a global scale, the International Foundation for Gastrointestinal Disorders estimates IBS affects 10% to 15% of the population, making it the most prevalent disorder of gut-brain interaction.
Source: Cleveland Clinic
“IBS is one of the disorders of gut-brain interaction, or DGBIs, where patients have chronic gastrointestinal symptoms due to pathophysiologic mechanisms that involve the way the brain and the gut communicate,” Lin Chang, MD, vice chief of the Vatche and Tamar Manoukian Division of Digestive Diseases at the University of California, Los Angeles, told Healio Gastroenterology.
Symptoms can range from mild inconvenience to severe debilitation with a clinical phenotype that is “really diverse,” ACG vice president William D. Chey, MD, AGAF, FACG, FACP, H. Marvin Pollard Professor of Gastroenterology and chief of gastroenterology and hepatology at Michigan Medicine, said.
Rome IV criteria differentiates IBS by bowel habit subtype, based on days with abnormal bowel movements. The subtypes include IBS with constipation (IBS-C), IBS with diarrhea (IBS-D) and IBS with mixed bowel habits (IBS-M).
Along with underlying abnormalities in motility, visceral sensation and gut microbiome, psychosocial distress and food may also worsen IBS symptoms. Further complicating the creation of a personalized management plan is that different triggers can lead to the same symptoms.
“Every patient is different, but the main point is for clinicians to understand the various tools for the different types of IBS patients they may encounter in clinical practice,” Chey said.
In this exclusive, Healio Gastroenterology spoke with experts across the field to understand how they approach patient care and how new research may help shape the future of IBS diagnosis and treatment.
Identifying IBS Subtype, Addressing Underlying Triggers
Once a diagnosis is established, it is critical to identify the patient’s predominant symptoms, any coexisting conditions and underlying triggers.
“Clinically, we first want to categorize patients by their predominant symptom,” Anthony Lembo, MD, director of research at the Digestive Disease Institute at Cleveland Clinic, said. “Usually it’s either by bowel habit, meaning constipation, diarrhea or a mixture, or by abdominal pain, because a lot of treatments are directed at these certain symptoms.”
When building a management plan, Lembo often starts by recommending lifestyle modifications.
“We spend time trying to figure out what their lifestyle is like and what could be modified, if anything, to help improve their symptoms,” he said. “This can include anything from exercise to stress to diet. Sometimes we will even encourage them to seek behavioral treatment for sleep.”
Along with lifestyle modifications, Chang also emphasized the importance of patient education, reassurance and identifying those factors that trigger symptoms.
“Often, patients with IBS have diets that differ from the general population and it may be that they alter their diet in response to their symptoms,” Lembo noted. “In those initial visits, I spend a lot of my time going through different foods that could be potential triggers. Diet is where we can really make the biggest and quickest impact.”
Chang added that although pharmacologic management is often used for some patients, it is not always necessary for those with mild symptoms or for whom symptoms are not bothersome and do not impact relationships and daily activities.
When patients have moderate to severe symptoms, introducing pharmacologics such as over-the-counter remedies and prescription medications may be useful to build upon management strategies that have already been adopted. Severe symptoms, which Chang defined as being “very impactful on daily activities,” often require a multidisciplinary and interdisciplinary care approach with a team of medical doctors, dietitians, brain-gut behavioral specialists and, in some cases, complimentary alternative medicine providers. This integrated approach may also be considered in patients with less severe symptoms.
“If I were to give advice, I would try to emphasize that the impact of a patient’s quality of life can be quite significant,” Lembo said. “While patients with IBS do not have increased inflammation or other obviously identifiable pathology, the impact of their symptoms can be significant, particularly those living with it day in, day out.”
He continued: “Having empathy and an understanding of what they are going through can go a long way.”
Pharmacologic Treatments for IBS Subtypes
Though experts agreed that they prioritize lifestyle modifications in IBS management, positioning FDA-approved and OTC therapies in a patient’s care plan may be a suitable option. In fact, the AGA released the first pharmacologic treatment plan for patients with IBS and its subtypes, IBS-C and IBS-D, in 2022.
“The guideline provides a very good outline of the agents that might be used as first- and second-line treatment and thereafter,” Chey said. “I don’t deviate terribly from what is recommended in the guidelines, though everybody’s going to have their own little nuances. For example, I like peppermint oil more than I like hyoscyamine, and I rarely use alosetron but I use ondansetron all the time.”
“The key thing is for physicians to understand what their medical options are and where those options might be most effective,” Chey added.
For patients with IBS-C, guideline highlights include:
- For first-line treatment of patients with IBS-C experiencing mild constipation and abdominal pain, experts recommend osmotic laxatives, like polyethylene glycol, and antispasmodics such as hyoscyamine and peppermint oil.
- For second-line treatment of moderate symptoms, experts recommend secretagogues such as linaclotide, lubiprostone, plecanatide and tenapanor.
- Third-line recommendations include treatment with tegaserod.
Among those with IBS-D, recommendations include:
- For first-line treatment of patients with IBS-D experiencing mild diarrhea and abdominal pain, experts recommend loperamide, a bile acid sequestrant (eg, colestipol) and antispasmodics such as hyoscyamine and peppermint oil.
- For second-line treatment of moderate symptoms, experts recommend rifaximin; low-dose tricyclic antidepressants, such as amitriptyline and desipramine; and eluxadoline.
- Third-line recommendations for patients with IBS-D experiencing severe symptoms include treatment with alosetron.
Experts further recommend low-dose tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors and brain-gut behavioral therapies if abdominal pain and/or psychological symptoms persist among patients with any IBS subtype.
According to Chang, recent updates to these guidelines state that tegaserod is “no longer available” and alosetron, which “used to be available in a risk mitigation plan,” can be ordered without risk mitigation or a restricted use plan.
Positioning Brain-Gut Behavioral Therapies
As the traditional focus of abnormalities in motility and visceral sensation has shifted to include psychosocial distress as one of the most important triggers of worsening symptoms in IBS, incorporating GI psychology has played a larger role in disease management.
According to a 2018 clinical practice update published in Gastroenterology, brain-gut behavioral therapies like cognitive-behavior therapy and gut-directed hypnotherapy have the capacity to reduce health care utilization and symptom burden. As such, researchers recommended that gastroenterologists routinely assess a patient’s health-related quality of life and refer to a health psychologist or medical social worker when necessary.
“Therapy is typically short-term, goal-oriented, skills-based and focused on the impact the digestive symptoms are having on the person’s life and well-being,” Meredith R. Craven, PhD, MPH, clinical assistant professor and director of GI health psychology at Stanford Medicine, previously told Healio Gastroenterology. “We use evidence-based, brain-gut behavior therapies, such as cognitive-behavior therapy or gut-directed hypnotherapy. These therapies can improve symptoms, decrease health care utilization and improve coping, resilience and well-being.
“Even better, brain-gut behavior therapies are durable, with patients experiencing long-term benefits even after completing therapy.”
While this modality of care has proven to help patients increase their quality of life, Lembo noted that it is “not realistic” for most people, as lack of access and resources remain the largest barrier to care.
“That being said, there are avenues that are completely available,” he said. “Digital health apps, that are either FDA-approved or just available to the public, are opportunities for those who aren’t at the Cleveland Clinic to receive multidisciplinary care.”
Though the list of available digital therapeutic resources is continually evolving, notable programs that deliver behavioral treatment and symptom tracking include Nerva, Zemedy, Mahana IBS, Regulora, Dieta, mySymptoms and Cara Care.
Incorporating Established Dietary Intervention Plans
Like any other IBS management strategy, dietary intervention must be personalized with the patient’s best interests and health history in mind. Although there are many dietary intervention strategies to choose from, the effectiveness and popularity of the low-FODMAP diet has been proven time and time again, while also being backed by robust research and evidence.
According to Chey, the low-FODMAP diet “has been revolutionary” in the management of patients with IBS.
In a meta-analysis published in Gut, researchers reported that a low-FODMAP diet was more effective in improving global IBS symptoms compared with habitual diet (RR = 0.67; 95% CI, 0.48-0.91) and was “superior to all other interventions.” The low-FODMAP diet was also most effective for combatting abdominal pain, bloating or distension severity. Further, results from a randomized, open-label parallel-group trial, also published in Gut, showed that an app-based, low-FODMAP intervention was significantly more likely to lead to an improvement in overall IBS symptoms (> 50-point reduction in IBS symptom severity score) at 8 weeks compared with 40 mg otilonium bromide three times per day (71% vs. 61%), with durable benefits seen at 6 months.
Though the low-FODMAP diet is tried and true, Chey noted there is no one-size-fits-all dietary solution for patients with IBS.
“The low-FODMAP diet has kicked the door open in terms of diet therapy for IBS, but it shouldn’t be viewed as the one and only diet therapy,” he said. “It is really important for clinicians to recognize, for example, that there are patients with abnormal eating behaviors who should not be following the low-FODMAP diet.”
In the last year, new research has shed light on the potential effectiveness and feasibility of the Mediterranean diet.
According to data published in Alimentary Pharmacology & Therapeutics, patients with IBS who were randomized to Mediterranean Diet Adherence Screener scores at 6 weeks (7.5; 95% CI, 6.9-8 vs. 5.7; 95% CI, 5.2-6.3), as well as a greater score increase (2.1; 95% CI, 1.3-2.9 vs. 0.5; 95% CI, 0.1-1), than those who continued their usual diet. Moreover, there was a higher proportion of GI symptom (83% vs. 37%) and depression (52% vs. 20%) responders in the Mediterranean diet group.
“The Mediterranean diet is a feasible and potentially therapeutic dietary intervention for managing gut and psychological symptom burden in IBS,” the researchers wrote. “The broader health benefits associated with a Mediterranean-style diet provide further impetus for studying its effects in this population.”
Beyond specific dietary interventions, Chey noted there are many other healthy eating recommendations that can help patients to manage their symptoms such as those from the British Dietetic Association and the National Institute for Health and Care Excellence, or NICE.
Highlights from both guidelines include:
- Patients with IBS should take time to eat, consume meals at regular intervals and either avoid missing meals or leaving long gaps between eating.
- Experts recommended patients drink at least 8 cups of fluid per day, especially water or other non-caffeinated beverages, restrict tea and coffee intake to 3 cups per day and reduce intake of alcohol and fizzy drinks.
- Patients should reduce their intake of high-fiber foods, such as whole meal or high-fiber flour and breads, as well as intake of resistant starch often found in processed or re-cooked foods. Experts further recommended patients limit their intake of fresh fruit to three portions or 240 g per day.
- Patients with IBS-D should avoid sorbitol.
“Providing common sense recommendations, as provided by the NICE guidelines and [those] produced by the British Dietetic Association, can benefit a significant proportion of IBS patients,” Chey said.
Evolving Diagnostic, Management Strategies
While the current standard of care for patients with IBS is based on their most bothersome symptoms and disease subtype, many underlying pathophysiological factors and triggers can lead to the same symptoms. For this reason, Chey noted that symptoms are a “very blunt instrument” when choosing between treatment approaches.
“Indeed, most ‘effective’ IBS treatments make around half of patients better,” he said. “In the future, it is hoped that diagnostics will be developed that help a provider understand the cause of a patient’s symptoms. This might allow providers to choose the right treatment for the right patient.”
Moving forward, Chang added that development is underway on devices that measure objective biomarkers of symptom severity, as well as interest in researching alternative treatment approaches such as virtual reality programs, resiliency training and yoga. Additionally, microbiome-based therapies may prove to be beneficial in altering symptom response.
“The goal is to move from empiric therapy to more of a precision-medicine model,” Chey said. “We are still at the very early stages, but these are truly exciting times for patients with DGBIs and the providers who care for them.”
- References:
- Almario CV, et al. Gastroenterology. 2023;doi:10.1053/j.gastro.2023.09.010.
- Black CJ, et al. Gut. 2021;doi:10.1136/gutjnl-2021-325214.
- Carbone F, et al. Gut. 2022;doi:10.1136/gutjnl-2021-325821.
- Chang L, et al. Gastroenterology. 2022;doi:10.1053/j.gastro.2022.04.016.
- Chey WD, et al. Gastroenterology. 2022;doi:10.1053/j.gastro.2021.12.248.
- Chey WD. The end of the beginning: Megatrends in gastroenterology. Presented at: ACG Annual Scientific Meeting; Oct. 22-27; Las Vegas (hybrid meeting).
- International Foundation for Gastrointestinal Disorders. Facts about IBS. https://aboutibs.org/what-is-ibs/facts-about-ibs/. Accessed Feb. 15, 2024.
- Keefer L, et al. Gastroenterology. 2018;doi:10.1053/j.gastro.2018.01.045.
- Lembo A, et al. Gastroenterology. 2022;doi:10.1055/j.gastro.2022.04.017.
- McKenzie YA, et al. J Hum Nutr Diet. 2016;doi:10.1111/jhn.12385.
- National Institute for Health and Care Excellence: Irritable bowel syndrome in adults: Diagnosis and management. https://www.nice.org.uk/guidance/cg61. Accessed Feb. 23, 2024.
- Staudacher HM, et al. Aliment Pharmacol Ther. 2023;doi:10.1111/apt.17791.
- For more information:
- Lin Chang, MD, is vice chief of the Vatche and Tamar Manoukian Division of Digestive Diseases at the University of California, Los Angeles and can be reached at linchang@mednet.ucla.edu.
- William D. Chey, MD, AGAF, FACG, FACP, is H. Marvin Pollard Professor of Gastroenterology and chief of gastroenterology and hepatology at Michigan Medicine and can be reached at wchey@med.umich.edu.
- Anthony Lembo, MD, is director of research at the Digestive Disease Institute at Cleveland Clinic and can be reached at lemboa2@ccf.org.
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