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Irritable Bowel Syndrome Medication

  • Author: Jenifer K Lehrer, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Jun 16, 2015
 

Medication Summary

The selection of pharmacologic treatment remains symptom directed. Agents used for management of symptoms in irritable bowel syndrome (IBS) include anticholinergics, antidiarrheals, tricyclic antidepressants, prokinetics, bulk-forming laxatives, serotonin receptor antagonists, chloride channel activators, and guanylate cyclase C (GC-C) agonists.

A Cochrane systematic review found that several antispasmodics, including peppermint oil, pinaverium, trimebutine, and cimetropium/dicyclomine, significantly outperformed placebo at improving IBS symptom and global assessment scores.[5]

The 2009 ACG position statement on management of IBS noted that the antidiarrheal agent loperamide effectively reduced stool frequency and improved stool consistency, but it did not relieve pain, bloating, or other global IBS symptoms.[4]

Investigational use

A total of 1260 patients with IBS without constipation were enrolled in the TARGET 1 and TARGET 2 phase III trials at 179 investigative sites in the United States and Canada. Results showed that treatment with rifaximin (550 mg PO tid for 14 d) provided better symptom relief (eg, bloating, abdominal pain, loose/watery stools) compared with placebo, although the placebo effect was tremendous. Similarly, a 2012 meta-analysis of 5 studies, incorporating 1,803 patients, determined that rifaximin is more effective than placebo for global symptom relief and bloating. Adverse event rates were similar to placebo.[26] Rifaximin is not yet approved by the US Food and Drug Administration for IBS.[27]

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IBS Agents

Class Summary

Linaclotide and lubiprostone enhance chloride-rich intestinal fluid secretions without altering sodium and potassium concentrations in the serum. Linaclotide was approved by the FDA in August 2012 to treat chronic idiopathic constipation and irritable bowel syndrome with constipation (IBS-C) in adults.[29]  The safety and efficacy of linaclotide to treat IBS-C were evaluated in 2 double-blind, placebo-controlled phase III clinical trials in which linaclotide met all 4 primary endpoints for changes in abdominal pain and constipation in each trial. The trials involved 1,605 patients aged 18-87 years, of which 807 were treated with linaclotide 290 mcg. Both trials showed a significantly higher proportion of responders in the linaclotide group compared with the placebo group.[30, 31]

Lubiprostone (Amitiza)

 

This agent activates chloride channels on the apical part of the small bowel epithelium. As a result, chloride ions are secreted and sodium and water passively diffuse into the lumen to maintain isotonicity. This medication is FDA approved for use in idiopathic constipation and in irritable bowel syndrome with constipation.

Alosetron (Lotronex)

 

Alosetron is a 5-HT3 receptor antagonist. This agent controls irritable bowel syndrome symptoms through its potent and selective antagonism of serotonin 5-HT3 receptor type. These receptors are extensively located on enteric neurons of the GI tract, and stimulation causes hypersensitivity and hyperactivity of the intestine. It is indicated only for women with severe diarrhea-predominant IBS who have: chronic IBS symptoms (generally lasting 6 months or longer), had anatomic or biochemical abnormalities of the GI tract excluded, and not responded adequately to conventional therapy.

Limiting its use to this severely affected population is intended to maximize the benefit-to-risk ratio. The drug was previously removed from the US market but was reintroduced with new restrictions approved by the FDA on June 7, 2002. Restrictions are because of reports of infrequent but serious GI adverse reactions (eg, ischemic colitis, serious complications of constipation), including some that resulted in hospitalization and, rarely, blood transfusion, surgery, or death. In order to prescribe, physicians must be enrolled in the Prescribing Program for Lotronex.

Under the new management plan, serious adverse events have been few.[28]

Linaclotide (Linzess)

 

GC-C agonist; activation of GC-C receptors in the intestinal neurons leads to increased cyclic guanosine monophosphate (cGMP), anion secretion, fluid secretion, and intestinal transit; it appears to work topically rather than systemically; when administered PO, linaclotide activates chloride channels in intestinal epithelial cells to increase intestinal fluid secretion; indicated to treat chronic idiopathic constipation and for IBS-C in adults.

Eluxadoline (Viberzi)

 

Eluxadoline is a mu opioid receptor agonist. It also is a delta opioid receptor antagonist and a kappa opioid receptor agonist. The multiple opioid activity is designed to treat the symptoms of IBS-D while reducing the incidence of constipation that can occur with unopposed mu opioid receptor agonists. It is indicated for IBS-D in adult men and women.

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Anticholinergics

Class Summary

Anticholinergic agents are antispasmodics that inhibit intestinal smooth-muscle depolarization at the muscarinic receptor. These agents help relieve symptoms of intestinal spasms in irritable bowel syndrome.

Dicyclomine hydrochloride (Bentyl)

 

Dicyclomine blocks the action of acetylcholine at parasympathetic sites in secretory glands, smooth muscle, and CNS. This drug decreases fecal urgency and pain. It is useful in patients with diarrhea-predominant symptoms. Adverse effects are dose dependent.

Hyoscyamine sulfate (Levsin)

 

Like dicyclomine, hyoscyamine is useful in patients with diarrhea-predominant symptoms and blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS, which, in turn, has antispasmodic effects. The drug decreases fecal urgency and pain.

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Antidiarrheals

Class Summary

These agents are nonabsorbable synthetic opioids. They prolong GI transit time and decrease secretion via peripheral µ-opioid receptors. They reduce visceral nociception via afferent pathway inhibition.

Diphenoxylate hydrochloride 2.5 mg with atropine sulfate 0.025 mg (Lomotil)

 

This drug combination consists of 2.5 mg of diphenoxylate, which is a constipating meperidine congener, and 0.025 mg of atropine to discourage abuse. The preparation inhibits excessive GI propulsion and motility, but it may exacerbate constipation.

Loperamide (Imodium)

 

Loperamide, which is available over the counter, acts on intestinal muscles to inhibit peristalsis and to slow intestinal motility. It prolongs movement of electrolytes and fluid through bowel and increases viscosity and loss of fluids and electrolytes. Loperamide improves stool frequency and consistency, reduces abdominal pain and fecal urgency, and may exacerbate constipation.

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Tricyclic Antidepressants

Class Summary

Tricyclic antidepressants have both antidepressive and analgesic properties. Agents such as imipramine and amitriptyline are efficacious in treating symptoms of irritable bowel syndrome. The use of tricyclic antidepressants in irritable bowel syndrome is off label.

Imipramine (Tofranil)

 

Imipramine increases pain threshold in the gut, thereby providing a visceral analgesic effect. It prolongs oral-cecal transit time; reduces abdominal pain, mucorrhea, and stool frequency; and increases global well-being variably in studies. It is effective in irritable bowel syndrome in doses subtherapeutic for antidepressive actions, suggesting an independent mechanism of action in this disorder.

Amitriptyline (Elavil)

 

Like imipramine, amitriptyline provides a visceral analgesic effect at doses subtherapeutic for antidepressive actions. It also prolongs oral-cecal transit time, reduces abdominal pain, mucorrhea, and stool frequency, and increases global well-being variably in studies.

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Antibiotics

Class Summary

Antibiotics may play a role in the treatment of irritable bowel syndrome by preventing the overgrowth of intestinal bacteria.

Rifaximin (Xifaxan)

 

Rifaximin is a semisynthetic derivative of rifampin and acts by binding to the beta-subunit of bacterial DNA-dependent RNA polymerase, blocking one of the steps in transcription. This results in inhibition of bacterial protein synthesis and consequently inhibits the growth of bacteria. The exact mechanism of action for IBS-D is not known, but it is thought to be related to changes in the bacterial content in the gastrointestinal tract and reduction of gas. It is indicated for IBS-D in adult men and women.

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Bulk-Forming Laxatives

Class Summary

These products are made of natural and semi-synthetic hydrophilic polysaccharides and cellulose derivatives that dissolve or swell in the intestinal fluid, forming emollient gels that facilitate passage of intestinal contents and stimulate peristalsis. As fiber supplements, these products may improve symptoms of constipation and diarrhea, but their use in irritable bowel syndrome is controversial.

Methylcellulose (Citrucel)

 

This agent promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.

Psyllium (Metamucil, Fiberall, Reguloid, Konsyl)

 

Like methylcellulose, psyllium promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.

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Contributor Information and Disclosures
Author

Jenifer K Lehrer, MD Attending Physician, Department of Gastroenterology and Hepatology, Aria Health System, Philadelphia

Jenifer K Lehrer, MD is a member of the following medical societies: American College of Gastroenterology, American Medical Association, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Gary R Lichtenstein, MD Professor of Medicine, Director, Center for Inflammatory Bowel Disease, Department of Medicine, Division of Gastroenterology, University of Pennsylvania School of Medicine

Gary R Lichtenstein, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rajeev Vasudeva, MD, FACG Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

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