Treatment Options for Irritable Bowel Syndrome in Adults

1st Line Options 2nd Line Options

Antispasmodics - with dietary and Antimotility Laxatives If laxatives, loperamide or antispasmodics have lifestyle advice (Adjust to clinical response) (Adjust to clinical response) not helped, consider tricyclic antidepressants as 2nd Line.

st 1 Choice - Direct-acting smooth muscle Avoid use of lactulose 1st Choice – Loperamide- licensed for relaxants mebeverine, peppermint oil OR 1ST Choice – Tricyclic Antidepressants (TCA) symptomatic treatment of acute alverine E.g. amitriptyline episodes of diarrhoea associated with (Unlicensed indication) There is good evidence that mebeverine IR IBS in adults. Consider Bulk forming laxatives, and MR are equally effective – but the IR is increase dose gradually e.g. Fybogel®

lower cost Start at a low dose e.g. 5mg to 10mg amitriptyline, which should be taken once at night and reviewed regularly. Caution: Colpermin® contains arachis oil Loperamide- dose of 4 mg initially, Flatulence and bloating are the most The dose may be increased but should not usually need (IR immediate release, MR modified followed by 2 mg after every loose common adverse effects of bulk- to exceed 30 mg a day. release) stool, up to a maximum of 12 mg per forming laxatives. They can usually day, for diarrhoea-predominant be avoided or reduced by increasing If TCAs have been shown to be irritable bowel syndrome. Liquid the dose of the laxative gradually ineffective, are contraindicated, or Note: Antimuscarinics such as hyoscine preparation helpful to those requiring every few days until ONE or TWO are not tolerated. butylbromide and dicycloverine are poorly low doses as they are very sensitive soft formed stools are produced selective and are more likely to cause to the effects of loperamide Advise every 1-2 days nd antimuscarinic adverse effects than direct- people to adjust the dose of 2 Choice - Selective serotonin reuptake inhibitors acting smooth muscle relaxants or loperamide according to clinical (SSRIs) - Citalopram, fluoxetine, and paroxetine -licensed peppermint oil. response. The aim is to produce a indication. An adequate fluid intake is important Dicycloverine is not recommended for soft, well-formed stool. to prevent intestinal obstruction. prescribing as it is poorly selective, more Bulk-forming laxatives should not be . likely to cause anti-muscarinic adverse Citalopram: 10 mg to 20 mg daily. taken immediately before going to . effects and there are lower cost Fluoxetine: 20 mg daily. Probiotics: if the patient wishes to bed. . alternatives with relatively fewer adverse Paroxetine: 10 mg to 20 mg daily try probiotics, advise them to choose effects and self-purchase one brand and take There is little difference in efficacy the recommended dose for at least 4 Eluxadoline in line with NICE TA 471 is an option for Consider adding or switching to between different antispasmodics. weeks but discontinue if no benefit IBS-D (IBS with Diarrhoea) if the condition has not Laxido® or bisacodyl Refer to the prescribing guidance on after 8 weeks responded to other pharmacological treatments (for anticholinergic drugs example, anti-motility agents, antispasmodics, tricyclic antidepressants) or pharmacological Patients with IBS-C (IBS with Constipation) that have failed a SIX month trial of at least two laxatives from different treatments are contraindicated or not tolerated, classes at optimal/maximum tolerated doses may be suitable for a trial of linaclotide – refer to gastroenterology via and it is started in secondary care. Refer to CRS with a full laxative history for the specialist to initiate a trial. gastroenterology via CRS with a full drug history. If beneficial, Specialist will recommend in writing to the GP to continue the prescribing Note risk of pancreatitis MHRA Dec 2017

Produced by the Medicines Optimisation Team at WECCG and updated in collaboration with the Gastroenterology department at PAH Approved by MOPB December 2019, Review Date December 2021 2019