Best management of irritable bowel syndrome (2024)

Abstract

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction which can have a considerable impact on quality of life. Following diagnosis, timely and evidence-based management is vital to the care of patients with IBS, aiming to improve outcomes, and enhance patient satisfaction. Good communication is paramount, and clinicians should provide a clear explanation about the disorder, with a focus on exploring the patient’s own beliefs about IBS, and a discussion of any concerns they may have. It should be emphasised that symptoms are often chronic, and that treatment, while aiming to improve symptoms, may not relieve them completely. Initial management should include simple lifestyle and dietary advice, discussion of the possible benefit of some probiotics, and, if this is unsuccessful, patients can be referred to a dietician for consideration of a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet. Antispasmodics and peppermint oil can be used first-line for the treatment of abdominal pain. If patients fail to respond, central neuromodulators can be used second-line; tricyclic antidepressants should be preferred. Loperamide and laxatives can be used first-line for treating diarrhoea and constipation, respectively. Patients with constipation who fail to respond to laxatives should be offered a trial of linaclotide. For patients with diarrhoea, the 5-hydroxytryptamine-₃ receptor agonists alosetron and ramosetron appear to be the most effective second-line drugs. Where these are unavailable, ondansetron is a reasonable alternative. If medical treatment is unsuccessful, patients should be referred for psychological therapy, where available, if they are amenable to this. Cognitive behavioural therapy and gut-directed hypnotherapy are the psychological therapies with the largest evidence base.

Introduction

Irritable bowel syndrome (IBS) is one of the most common disorders of gut-brain interaction, with a population prevalence of between 5% and 10%.1 2 The cardinal symptoms are abdominal pain, related to defaecation, associated with a change in the frequency or form of stools.3 Symptoms are chronic, often severe and have a substantial impact on quality of life.4 More than 80% of patients will consult their general practitioner (GP),5 and the majority are managed successfully in this setting.6 However, some patients, particularly those who fail to respond to first-line treatment, or those in whom there is any diagnostic uncertainty, for example, older patients in whom underlying organic pathology may need to be excluded, will be referred to secondary care. Managing patients with IBS accounts for approximately 25% of a gastroenterologist’s time in the outpatient clinic,7 and the associated costs of investigation and treatment are considerable.8

When reviewing any patient with IBS, the first consideration should be the requirement for any further investigation. We have previously written about the importance of adopting a rational approach, which prioritises making a diagnosis on clinical grounds in the majority of cases, following a limited number of essential investigations, for example, routine bloods, including coeliac serology.9 Exhaustive investigation is not only undesirable, but unnecessary, as tests are frequently normal, and this is likely to make patients feel that the cause of their symptoms has been missed, rather than providing reassurance.10 Indeed, taking a rational approach to investigation, and making an early diagnosis, are key components of recommendations calling for physicians to standardise the care of patients with IBS, with the aim of improving the quality of care overall, and enhancing patient satisfaction.11 The next step is to start treatment in a timely fashion, ideally during the first consultation if the diagnosis is secure and the relevant limited diagnostic tests to exclude another condition have already been performed in primary care. However, there is a recognition that confidence in managing IBS will vary between physicians, dependent on expertise.

In general, treatment is targeted at addressing a patient’s most troublesome symptoms, be that abdominal pain, diarrhoea, constipation or bloating. Although several factors have been implicated in the pathophysiology of IBS, including the gut-brain axis, alterations in the microbiome, genetic factors and visceral hypersensitivity, there is currently no role for using these to guide therapy in routine practice. Moreover, it is likely that, even among patients with the same symptoms, the underlying pathophysiology responsible for them will vary. Consequently, although treatments may be designed to address theoretical pathophysiological abnormalities, there is no way to assess response through objective measurement of these and, instead, the clinician must rely on patient-reported symptom response to determine treatment success.

This review aims to provide physicians with a practical, comprehensive and evidence-based framework for treating IBS (figure 1). It will focus on the importance of good communication, the role of dietary and lifestyle advice and second-line dietary strategies. First-line and second-line drug treatments will be evaluated, as will newer second-line treatments targeting abnormal stool form specifically. Finally, the place of psychological therapies in IBS will also be discussed. One problem with randomised controlled trials (RCTs) of therapies is that, in most IBS treatment trials, active drugs are compared with a placebo, rather than with each other. Therefore, the absence of head-to-head treatment comparisons makes it difficult to understand the relative efficacy of drugs, which is important when doctors and patients are choosing treatments. Network meta-analysis can circumvent this problem, to some extent, by providing the likelihood of which treatment is likely to be the most efficacious in each clinical scenario, and the findings from these types of evidence synthesis will be discussed, where available (table 1).

The importance of good communication

Before embarking on the prescription of any treatment, it is vital to recognise the role that good communication plays in management. An online survey of people with IBS revealed that many had a negative view of their relationship with healthcare professionals, with concerns about not being heard and a lack of empathy.12 Indeed, patients report a sense of frustration and isolation, reporting that consultation with medical experts rarely clarified their understanding of IBS or improved their management.13 This might in part reflect unrealistic expectations of patients, many of whom report a willingness to try any treatment in their desperation for a cure, only to be left disappointed when symptoms are not relieved completely.14 However, it also reflects a mismatch between patients’ ideal expectations of a consultation, and the reality of their experiences. In one survey of over 1000 patients, more than 90% wanted their doctor to give comprehensive information about IBS and provide sources for additional information, to listen well and answer questions, and to provide information about medication. Unfortunately, in recalling their prior experiences of healthcare, only 40% felt that their doctor provided information, 64% felt they had been listened to and 47% felt supported.

Equally, many patients have significant misconceptions regarding the nature of IBS and the prognosis. In one questionnaire study of over 250 patients with IBS, less than one-third knew abdominal pain was a key symptom, 40% thought colonoscopy could diagnose IBS, 30% believed IBS increased the risk of developing inflammatory bowel disease and one in seven believed that IBS could lead to cancer.15 There are also issues with doctors’ perceptions of IBS; the majority of GPs in one study believed it was primarily a psychological disorder,16 or in another survey a response to stress.17 Moreover, a qualitative study revealed that many doctors hold two contrasting views of IBS, the first being a publicly expressed ‘medical’ definition, and the second being a private view, incorporating their own experiences of managing patients and absorbed prejudices.18

It is therefore clear that there is a mismatch between views of doctors and patients regarding IBS, which may limit the usefulness of the patient-clinician interaction. A recent systematic review identified five practices that help foster a more positive, meaningful and engaged consultation.19 First, doctors should prepare with intention, taking a moment to focus before greeting a patient. Second, they should listen intently and completely. Third, they should explore what the patient cares about, and agree on what matters most, setting priorities in partnership. Fourth, they should seek to connect with the patient’s story, considering life experiences that influence their health, as well as acknowledging positive action and success. Finally, doctors should explore the patient’s emotions, taking note of any emotional cues.

Adopting this holistic approach has the potential to improve outcomes for patients with IBS,20 ensuring that their ideas and concerns are elicited. It is also vital to provide a clear explanation about the nature of IBS as a functional disorder and what this means, including why investigations have been normal, and that this is expected. Patient expectations should also be managed appropriately with discussion focussing on the prognosis of IBS, explaining that around two-thirds of patients experience chronic symptoms,21 with treatment targeted at improving symptoms, rather than complete symptom relief. Finally, doctors should outline treatment options, including the role of second-line treatment if initial management strategies prove unsuccessful. All of this will take more time than the standard allotted to a new or follow-up appointment in clinic. In our specialist clinic we allow 30 min for a new patient consultation, and 15 min for a follow-up. We usually allow patients a minimum of two follow-up visits, before returning them to the care of their GP, in order to allow commencement of treatments not available in primary care, with assessment of their efficacy.

General dietary and lifestyle advice

A discussion of simple dietary and lifestyle advice should be part of the care of all patients with IBS. The concept of self-help is important in empowering patients to take control of managing their condition.

Specialised dietary advice

If first-line dietary advice is ineffective, patients should be referred for assessment by a specialist dietitian. It is important to recognise that, although exclusion diets are commonplace in IBS management, the mechanisms by which they might work remain unclear. Dietetic assessment is key to ensuring that any diet is followed correctly, and that nutritional requirements are not compromised.

First-line drug treatments

If dietary and lifestyle advice are inadequate for improving symptoms, then a number of first-line drug treatments, targeting individual symptoms, should be considered.

Second-line drug treatments

Patients may report inadequate relief of symptoms with first-line treatments, and for patients who are referred to see a gastroenterologist, it is perhaps more likely that this will be the case. In this situation, second-line treatment with central neuromodulators, such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs), can be used. Again, this approach is endorsed by NICE guidelines.50 Their use is underpinned by the central role of the gut-brain axis in IBS pathophysiology. The central nervous system (CNS) and enteric nervous system (ENS) interact with each other in a bidirectional manner. The CNS may alter gut physiology, including motility or visceral sensitivity, for example altering bowel habit or the experience of pain, thereby triggering symptoms. Similarly, changes within the gut, including to the microbiome, can feed back to the brain, via the ENS, with effects on CNS function. Among patients with IBS at baseline, there is a significant increase in anxiety and depression at follow-up.67 The converse is also true; individuals with higher levels of anxiety and depression at baseline are significantly more likely to develop IBS subsequently.67 68 Central neuromodulators might act on pathways between gut and brain to improve IBS symptoms.

A systematic review and meta-analysis from 2019 identified 18 RCTS comparing TCAs or SSRIs with placebo in IBS, recruiting a total of 1127 patients, with a significant benefit in favour of central neuromodulators (RR=0.66; 95% CI 0.57 to 0.76). However, there was significant heterogeneity between studies, although only among trials of SSRIs. A subgroup analysis showed an overall benefit in favour of TCAs for abdominal pain, compared with placebo (RR=0.59; 95% CI 0.42 to 0.83). The effect of these drugs on bowel habit is unclear. Most studies did not recruit participants on the basis of stool form, nor did they evaluate specific stool consistency endpoints. Given that constipation is a frequently reported side effect of TCAs, these drugs may have a positive impact in IBS-D, but there is no clear evidence for this. Equally, using TCAs to treat abdominal pain in patients with IBS-C may exacerbate constipation. In terms of safety, eight RCTs provided data for total adverse events, with a significantly higher incidence with central neuromodulators (RR of any adverse event=1.56; 95% CI 1.23 to 1.98).

The relative efficacy of central neuromodulators has been compared with other ‘traditional’ treatments in a network meta-analysis.35 TCAs ranked second for effect on global IBS symptoms and first for effect on abdominal pain, whereas SSRIs ranked fifth for global symptoms and fourth for abdominal pain. However, we must interpret the results of this network meta-analysis cautiously. Quality of the evidence underpinning it was moderate at best, with few trials at low risk of bias, and many were conducted prior to standardised clinical definitions of IBS, and in small numbers of patients.

Overall, the available data supports the use of central neuromodulators for treating IBS, when first-line treatments are ineffective. TCAs should be preferred, and can be commenced at a low dose (eg, 10 mg at night, due to risk of drowsiness). The dose can be increased, depending on symptomatic response, although dose titration beyond 50 mg may lead to higher rates of adverse events. If symptoms do not improve, SSRIs are a reasonable alternative. Although there is no evidence from RCTs to support the use of serotonin norepinephrine reuptake inhibitors, they are beneficial in other chronic painful disorders,69 and there are reports of efficacy in some patients with IBS, particularly those with psychological comorbidity.70

Second-line drug treatments targeting abnormalities of stool form

As already discussed, antidiarrhoeals and laxatives can be used in the treatment of abnormal stool form; however, where these prove ineffective, second-line drugs targeting abnormalities in bowel habit are available.

Psychological therapies

The efficacy of a number of psychological therapies in IBS has been investigated. Among the most widely used is cognitive behavioural therapy (CBT). Early trials of CBT suggested it was efficacious in IBS,89 90 although individual trial results are conflicting, with some RCTs finding no benefit compared with standard IBS care.91 One problem with any trial of psychological therapy is the inability to blind participants to treatment, meaning studies are rarely at low risk of bias. Furthermore, sample sizes are often small, reflecting the intensive nature of psychological interventions, which often require a skilled practitioner working face-to-face with a motivated patient over several weeks. These practical constraints may limit availability in clinical practice. More recently, larger studies have examined the role of minimal-contact CBT,92 which participants can self-administer at home, or CBT delivered via the telephone or Internet.93 These approaches require therapist input, but at a reduced frequency, meaning they can be made more widely available. Results of these trials suggest these approaches are efficacious at improving IBS symptoms.92 93 The beneficial effects of CBT delivered over the telephone or via the Internet persisted up to 24 months after completion of treatment in one trial.94

Gut-directed hypnotherapy has also been used in IBS, and, again, small studies suggest it is efficacious,95 96 although it has been suggested that delivery outside specialist centres is less beneficial.97 Similar to CBT, treatment with hypnotherapy requires a skilled practitioner, but has been delivered remotely in one uncontrolled study.98 Group hypnotherapy may also improve patient access to treatment. In a multicentre RCT comparing individual and group hypnotherapy with educational support as a control, hypnotherapy was significantly more efficacious than education for adequate relief of symptoms at 3 months and, in a per-protocol analysis, group hypnotherapy was non-inferior to individual hypnotherapy.99

In a network meta-analysis comparing all available psychological therapies with each other that included 41 RCTs, comprising 4072 participants, treatments with the greatest evidence for efficacy, having both the largest number of trials and recruiting the greatest numbers of patients, were self-administered or minimal contact CBT (RR=0.61; 95% CI 0.45 to 0.83), face-to-face CBT (RR=0.62; 95% CI 0.48 to 0.80) and gut-directed hypnotherapy (RR=0.67; 95% CI 0.49 to 0.91).100 However, it is important to emphasise no psychological therapy was superior, in terms of efficacy, to any other. When only those trials that recruited patients with refractory symptoms were included, again CBT-based interventions, namely group CBT and minimal contact CBT, and gut-directed hypnotherapy were more efficacious than control interventions.

Overall, several psychological therapies are efficacious in IBS, although it remains difficult to know which should be preferred, and patient access may be limited. CBT-based treatment and gut-directed hypnotherapy have the largest evidence base, and CBT has demonstrated longer-term efficacy. NICE recommends psychological therapies for patients who remain symptomatic following medical treatment, but only after 12 months has elapsed.50 There is an argument for earlier deployment of such therapies, especially among patients with evidence of psychological comorbidity at baseline as, given our understanding of the role of the gut-brain axis, this could alter the clinical course of IBS, preventing symptoms from becoming refractory and improving outcomes. This should be a focus for future treatment trials.

Conclusions

Once a diagnosis of IBS is made, it is important to start timely treatment. Good communication is central to managing the condition, and there should be a focus on exploring patient beliefs about the condition, and any concerns they may have. Clinicians should provide a clear explanation about the disorder, and the rationale for any investigations, including why further investigation may not be necessary and why test results are normal. Initial management should include simple lifestyle and dietary advice, discussion of the potential role for probiotics and the importance of exercise and making time for leisure activities and relaxation. If these measures are ineffective, referral to a dietitian for consideration of a low FODMAP diet is appropriate. First-line drug therapy includes antispasmodics and peppermint oil for the treatment of abdominal pain. Loperamide and laxatives can be tried for the treatment of diarrhoea or constipation, respectively, although evidence for their efficacy is limited.

If these approaches fail to improve symptoms, second-line treatments should be used. Central neuromodulators are useful for their effects on global IBS symptoms and abdominal pain; TCAs should be preferred. For patients with constipation who fail to respond to laxatives, treatment with linaclotide should be offered. Unfortunately, second-line options for the treatment of diarrhoea are limited in some countries. 5-HT₃ receptor agonists appear to be the most efficacious, and although alosetron or ramosetron are not widely available, ondansetron may be a reasonable alternative. Patients who fail to respond to medical treatment should be referred for consideration of psychological therapy, if they are amenable to this. CBT and gut-directed hypnotherapy have the largest evidence base, but access to these treatments may be limited.

Ethics statements

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