eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology
Irritable Bowel Syndrome: Treatment & Medication
Updated: May 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Irritable bowel syndrome (IBS) is a chronic illness and has no cure.
- Treatment may be challenging and even frustrating to the physician, the patient, and the patient's family. The most important component of treatment is to establish an effective and therapeutic relationship with the patient and his or her family.
- Educate the child and parents that irritable bowel syndrome is a chronic illness that cannot be cured. At the same time, reassure them that it is not a life-threatening condition and it does not lead to physical impairment. Tell the patient and the family that the symptoms are real and respond to their worries and concerns. Reassurance is more effective if offered after a careful history and physical examination and a conservative diagnostic evaluation.
- Most patients have mild symptoms and maintain normal daily activities and regular school attendance. Address the possible dietary and psychosocial triggering factors. Counseling, dietary modifications, and lifestyle changes are usually effective and sufficient for treatment.
- A smaller proportion of patients have moderate-to-severe symptoms with some disruption of their activities and school performance. This group of patients may benefit from pharmacotherapy and behavioral treatment. Referral to a psychologist may be required.
Consultations
- Consider further evaluation and a referral to a pediatric gastroenterologist if findings from the patient's history, physical examination, or screening laboratory tests are suggestive of organic disease.
Diet
- Dietary modification
- Some patients with irritable bowel syndrome report exacerbation of their symptoms after ingestion of certain foods. Elimination of certain foods, such as sorbitol, fructose, and gas-forming legumes, achieves relief in some patients with irritable bowel syndrome, especially those with excess gas. Attempt lactose restriction in patients with documented lactose malabsorption.
- Foods associated with increased flatulence include onions, beans, celery, carrots, prunes, bananas, raisins, brussel sprouts, wheat germ, and bagels.
- Fiber supplements
- A high-fiber diet or supplement is useful in patients with constipation-predominant irritable bowel syndrome. Several studies have demonstrated that fiber enhances water-retentive properties of stool, increases stool weight, and accelerates colonic transit.
- In general, dietary fibers are less soluble and more effective as bulking agents, whereas synthetic fibers are more soluble and increase water retention.
- The recommended daily intake of fiber (in grams) for children is estimated by adding 5 to their age in years.
Medication
Pharmacotherapy is recommended for patients with moderate-to-severe irritable bowel syndrome (IBS) symptoms that cause disruptions in activity. Treatment is symptomatic and is directed at the most predominant symptom (eg, dietary fiber supplementation and stool softeners for constipation, antidiarrheals for diarrhea, smooth muscle relaxants for pain). A better understanding of the pathophysiology of irritable bowel syndrome and the role of neurotransmitters and receptors involved in the GI sensory and motor functions have provided opportunities for the development of newer therapeutic agents. The role of serotonin in the pathophysiology of irritable bowel syndrome has drawn much attention, and agonists and antagonists at 5-hydroxytryptamine (5-HT) receptors have been approved for the treatment of subgroups of patients with irritable bowel syndrome.
Antispasmodic and anticholinergic agents
These are the most frequently used medications (ie, hyoscyamine, dicyclomine) in the United States for the treatment of pain episodes in patients with irritable bowel syndrome. Results from adult studies on the efficacy of these medications have provided conflicting data. The meta-analysis of the use of smooth muscle relaxants (eg, cimetropium, otilonium bromide, pinaverium, mebeverine, trimebutine) by Poynard et al showed efficacy over placebo in irritable bowel syndrome.14 These drugs have calcium channel–blocking properties or antimuscarinic activities. No pediatric data are available with which to evaluate their efficacy or adverse effects.
Hyoscyamine (Levsin, Levbid)
Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and CNS, which in turn has antispasmodic effects.
Adult
Levsin: 0.125-0.25 mg (1-2 tab) PO/SL q4h prn; not to exceed 12 tab per d
Levbid: 0.375-0.75 mg PO bid
Pediatric
<2 years: 0.125-mg/mL gtt; repeat q4h PO prn
The following is an approximate dosage guide:
2.3 kg (5 lb): 3 gtt; not to exceed 18 gtt per d
3.4 kg (7.5 lb): 4 gtt; not to exceed 24 gtt per d
5 kg (11 lb): 5 gtt; not to exceed 30 gtt per d
7 kg (15 lb): 6 gtt; not to exceed 36 gtt per d
10 kg (22 lb): 8 gtt; not to exceed 48 gtt per d
15 kg (33 lb): 11 gtt; not to exceed 66 gtt per d
2-12 years: Use 1.25-5 mL of elixir (0.03125-0.125 mg) PO q4h prn; not to exceed 30 mL/d
The following is an approximate dosage guide:
10 kg (22 lb): 1.25 mL
20 kg (44 lb): 2.5 mL
40 kg (88 lb): 3.75 mL
50 kg (110 lb): 5 mL
>12 years: Administer as in adults
Effects decrease when used concurrently with antacids; toxicity increases when used concurrently with phenothiazines, amantadine, haloperidol, MAOIs, or TCAs
Documented hypersensitivity; obstructive uropathy; narrow-angle glaucoma; myasthenia gravis; obstructive GI tract disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients; some products contain sodium metabisulfite, which can cause allergic reactions
Dicyclomine (Bentyl)
Treats GI motility disturbances. Blocks action of acetylcholine at parasympathetic sites in secretory glands, smooth muscle, and CNS.
Reports show that administration of dicyclomine syrup in infants has been followed by serious respiratory symptoms, seizures, syncope, pulse rate fluctuations, and coma. Death has been reported.
Adult
20-40 mg PO qid; discontinue if not effective within 2 wk or if 80 mg qd is associated with adverse effects
Pediatric
<6 months: Contraindicated
>6 months to 2 years: 5-10 mg PO tid/qid 15 min ac; not to exceed 40 mg/d
>2 years to 12 years: 10 mg PO tid
>12 years: Administer as in adults
Effects decrease when used concurrently with antacids; coadministration with anticholinergic drugs (eg, antihistamines, TCAs) may increase toxicity
Documented hypersensitivity; obstructive uropathy; obstructive disease of GI tract; severe ulcerative colitis; toxic megacolon; reflux esophagitis; glaucoma; myasthenia gravis; infants <6 mo
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause blurred vision or change in vision, severe constipation, urinary retention, and psychosis
Caution with hepatic or renal insufficiency, cardiovascular disease, urinary tract obstruction, ulcerative colitis, GI obstruction, hyperthyroidism, and hypertension
Antidiarrheal agents
These agents are used to treat diarrhea adjunctly with rehydration therapy to correct fluid and electrolyte depletion. They are usually helpful when diarrhea is the predominant symptom. Studies of the opiate agent loperamide show that it improves stool consistency, decreases stool frequency, and reduces abdominal pain. Cholestyramine acts by binding bile acids and can be helpful in some patients with irritable bowel syndrome. Alosetron and tegaserod are 5-HT4 receptor partial agonists that bind with high affinity at human 5-HT4 receptors. The activation of 5-HT4 receptors in the GI tract stimulates the peristaltic reflex and intestinal secretion and inhibits visceral sensitivity. In vivo studies showed that tegaserod enhanced basal motor activity and normalized impaired motility throughout the GI tract. In addition, studies demonstrated that tegaserod moderated visceral sensitivity during colorectal distension in animals.
Tegaserod was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment IND protocol. The treatment IND allows tegaserod treatment of irritable bowel syndrome with constipation or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease.
Earlier this year, tegaserod marketing was suspended because of a meta-analysis of safety data pooled from 29 clinical trials that involved more than 18,000 patients. The results showed an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. In each study, patients were assigned at random to either tegaserod or placebo. Tegaserod was taken by 11,614 patients, and placebo was taken by 7,031 patients. The average age of patients in these studies was 43 years, and most patients (ie, 88%) were women. Serious and life-threatening cardiovascular adverse effects occurred in 13 patients (0.1%) treated with tegaserod; among these, 4 patients had a heart attack (1 died), 6 had unstable angina, and 3 had a stroke. Among the patients taking placebo, only 1 (0.01%) had symptoms suggesting the beginning of a stroke that went away without complication.
For more information, see the FDA MedWatch Product Safety Alert.
Loperamide (Imodium)
Synthetic opioid; does not have central nervous action in therapeutic doses. Acts by slowing intestinal motility and enhancing water and electrolyte absorption. Reduces diarrhea and pain in patients with diarrhea-predominant IBS.
Adult
2-12 mg/d PO divided bid/tid; necessary doses differ greatly between individuals
Pediatric
<2 years: Not recommended
>2 years: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose
Phenothiazines, TCAs, and CNS depressants may increase toxicity
Documented hypersensitivity; diarrhea resulting from infections; pseudomembranous colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in severe ulcerative colitis or antibiotic-induced pseudomembranous colitis; monitor for CNS toxicity in patients with hepatic insufficiency because of decreased clearance
Cholestyramine (Prevalite, Questran)
Binds endogenous bile acids and can improve diarrhea in patients with unexplained diarrhea or idiopathic bile acid malabsorption.
Adult
3-4 g PO bid/qid mixed with fluid or food
Pediatric
240 mg/kg/d PO divided tid ac as slurry in water, juice, or milk
Inhibits absorption of numerous drugs including warfarin, thyroid hormone, amiodarone, NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin, methyldopa, tetracyclines, clofibrate, hydrocortisone, and penicillin G
Documented hypersensitivity; complete biliary obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in constipation and phenylketonuria
Alosetron (Lotronex)
Potent and selective antagonist of serotonin 5-HT3 receptor type. 5-HT3 receptors are extensively located on enteric neurons of GI tract, and stimulation causes hypersensitivity and hyperactivity of intestine. Alosetron blocks these receptors and, thus, is effective in controlling IBS symptoms.
Only approved for treatment in women with severe, chronic, diarrhea-predominant IBS that has failed to respond to conventional IBS therapy. Less than 5% of IBS is considered severe, and only a fraction of severe cases are diarrhea-predominant IBS. Limiting use to this severely affected population is intended to maximize the benefit-to-risk ratio. Previously removed from US market but reintroduced with new restrictions approved by FDA on June 7, 2002. Restricted because serious and unpredictable GI adverse events (some of which resulted in death) were reported in association with its use following original approval in February 2000.
Adult
Women: 0.5 mg PO bid for 4 wk initially; may increase to 1 mg PO bid if qd dose inadequate for controlling symptoms; discontinue if inadequate response to 1 mg bid after 4 wk
Men: Not established
Pediatric
Not established
Substrate of CYP450 isoenzymes 2C9, 3A4 (minor), and 1A2 (minor); coadministration with isoenzyme inhibitors (eg, cimetidine, fluvoxamine, fluoxetine, sertraline, metronidazole, omeprazole, co-trimoxazole) may decrease elimination and increase risk of toxicity; coadministration with isoenzyme inducers (eg, phenobarbital, fluconazole, carbamazepine, phenytoin) may increase clearance
Documented hypersensitivity; history of constipation, intestinal obstruction, stricture, toxic megacolon, GI perforation, adhesions, ischemic colitis, impaired intestinal circulation, thrombophlebitis, hypercoagulable state, Crohn disease, ulcerative colitis, or diverticulitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue immediately if serious GI adverse events occur (eg, ischemic colitis, serious complications of constipation); these adverse effects have resulted in hospitalization, blood transfusion, surgery, and death
Constipation is a dose-related adverse effect; elderly patients are more prone to GI risks; caution in hepatic insufficiency (decrease dose); pharmacists may only dispense prescriptions that display a prescribing program sticker affixed by an enrolled physician, and they must distribute a copy of the FDA-approved medication guide with each prescription; to enroll in the prescribing program call GlaxoSmithKline at 1-888-825-5249 or visit www.lotronex.com
Tegaserod hydrogen maleate (Zelnorm)
As of April 2008, no longer available in US. Previously available in US by restricted treatment IND for irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Indicated for the short-term treatment of women with irritable bowel syndrome in which constipation is the predominant symptom. Serotonin type 4 receptor partial agonist with no affinity for 5-HT3 receptors. May trigger peristaltic reflex via 5-HT4 activation, which enhances basal motor activity and normalizes impaired GI motility. Research studies have shown inhibitory activity of drug on visceral activity in GI tract.
Adult
Women: 6 mg PO bid 30 min ac for 4-6 wk; in patients who respond to treatment, an additional 4-6 wk of therapy may be considered
Men: Not established
Pediatric
Not established
None reported
Documented hypersensitivity; severe renal impairment; moderate or severe renal impairment; history of bowel obstruction, symptomatic gallbladder disease, suspected sphincter of Oddi dysfunction, or abdominal adhesions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Diarrhea may occur; do not give to patients with diarrhea; discontinue if new or sudden worsening of abdominal pain or diarrhea occurs; ischemic colitis and other forms of intestinal ischemia have been rarely reported (causality has not been established); discontinue immediately if symptoms of ischemic colitis (eg, rectal bleeding, bloody diarrhea, new or worsening abdominal pain) occur and evaluate immediately; do not resume treatment if findings consistent with ischemic colitis
Antidepressant drugs
Numerous studies have shown that TCAs (ie, imipramine, amitriptyline) can be useful in the treatment of irritable bowel syndrome in some patients. In addition to their antidepressant effects, TCAs have neuromodulatory and analgesic properties, which can be achieved at lower doses than those required for treatment of depression. Because of their inhibitory effect on gut motor function, TCAs may benefit patients with irritable bowel syndrome with predominant diarrhea or pain. TCAs particularly benefit patients with irritable bowel syndrome who have well-defined depression or panic attacks.
Amitriptyline (Elavil)
Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS.
Adult
10-50 mg/d PO qhs; administered at lower doses than required for depression
Pediatric
0.2-0.4 mg/kg/d PO qhs
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOIs within 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Cardiovascular disease; seizure disorder; urinary retention; adverse effects include sedation, urinary retention, constipation, dry mouth, dizziness, and arrhythmias; monitor ECG and BP at start of therapy and with dose changes
Imipramine (Tofranil)
Inhibits reuptake of norepinephrine or serotonin (5-HT) at presynaptic neuron.
Adult
10-50 mg/d PO qhs; administered at lower doses than required for depression
Pediatric
0.2-0.4 mg/kg/d PO qhs
Increases toxicity of sympathomimetic agents such as isoproterenol and epinephrine by potentiating effects and inhibiting antihypertensive effects of clonidine
Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; MAOIs within 14 d
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or concurrent thyroid replacement therapy
Monitor ECG and BP at start of therapy and with dose changes
Laxatives and stool softeners
These agents can be useful in patients with constipation-predominant irritable bowel syndrome. Osmotic laxatives (eg, magnesium hydroxide, lactulose, sorbitol) or stool lubricants (eg, mineral oil) are usually required for long-term therapy for children with moderate-to-severe constipation. Long-term studies have shown that these medications are safe and equally effective. Stimulant laxatives may be necessary intermittently and for short periods, but avoid prolonged use.
Mineral oil (Milkinol)
An emollient laxative that does not appear to have any pharmacologic action on the GI tract. Acts by lubrication. When taken for 2-3 d, penetrates and softens stool and may interfere with absorption of water. Generally is well tolerated and without major adverse effects. Onset of action is approximately 6-8 h. Indigestible; limited absorption.
Adult
15-45 mL PO qd or divided tid
60-150 mL PR as single dose
Pediatric
5-20 mL PO qd or divided tid
For chronic functional constipation: Up to 1.5-5 mL/kg/d
For disimpaction: Up to 30 mL per y of age bid; not to exceed 240 mL/d
30-60 mL PR as single dose
Decreases effect of docusate sodium and may decrease absorption of coumarin, PO contraceptives, and fat-soluble vitamins
Documented hypersensitivity; GERD, esophageal dysmotility, and dysphagia because of risk of aspiration and lipid pneumonitis; patients who are bedridden; infants <1 y; use with caution in children <5 y to minimize risk of aspiration
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Children <5 y; prolonged administration may produce a deficiency of fat-soluble vitamins; do not administer with food or meals (may cause aspiration, leading to lipid pneumonitis)
More on Irritable Bowel Syndrome |
| Overview: Irritable Bowel Syndrome |
| Differential Diagnoses & Workup: Irritable Bowel Syndrome |
 Treatment & Medication: Irritable Bowel Syndrome |
| Follow-up: Irritable Bowel Syndrome |
| Multimedia: Irritable Bowel Syndrome |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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Further Reading
The following are relevant clinical guidelines:
Keywords
irritable bowel syndrome, mucus colitis, spastic colon, irritable colon, functional bowel disease, IBS, functional gastrointestinal disorders, functional GI disorders, GI motility abnormalities, stomach pain, meal-stimulated pain, diarrhea, constipation-predominant irritable bowel syndrome, diarrhea-predominant irritable bowel syndrome, bladder dysfunction, orthostatic hypertension, anxiety, depression, personality disorders, hysteria, sexual abuse, physical abuse, gastroenteritis, bacterial gastroenteritis, abdominal pain, altered bowel movements, abdominal distension, dysmenorrhea, urinary frequency, arthritis, rectal bleeding, abdominal rigidity, lymphadenopathy, hepatosplenomegaly, treatment, diagnosis
