Release Date : April 26 2023
Irritable Bowel Syndrome: AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome with Diarrhea (2022)
About the Guideline
- This is one of two guidelines from the American Gastroenterological Association (AGA) on irritable bowel syndrome; this guideline focuses on irritable bowel syndrome (IBS) with a prevalence of diarrhea (IBS-D).
- The focus for this guideline and its eight recommendations are on the following:
- Pharmaceuticals to treat IBS-D: eluxadoline, rifaximin, alosetron, and loperamide
- Three classes of pharmaceuticals used to manage IBS: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and antispasmodics
- The target audience includes heath care providers in gastroenterology and primary care, patients, and regulators.
- The goal of the guideline is to provide supportive information to patients and healthcare providers about the risks and benefits of pharmaceutical treatment decisions for IBS-D; the guideline is not intended to prescribe a standard of care.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you work in an acute care setting.
Overview
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- IBS is defined as a chronic, highly prevalent disorder of gut-brain interaction.
- IBS is oMen debilitating, with a prevalence of approximately 4% worldwide (if assessed using Rome IV criteria) and approximately 10% worldwide (if assessed using Rome III criteria).
- IBS most commonly affects women and younger people.
- Although IBS is not life-threatening, it results in a diminished quality of life and in difficulty performing activities of daily living.
- IBS-D is a subtype of IBS and accounts for 30% to 40% of all cases.
- The use of the symptom-based Rome IV criteria, a thorough medical history, and a physical exam with a comprehensive assessment of gastrointestinal symptoms (alarm symptoms in particular) can lead to a positive diagnosis; minimal diagnostic tests are needed.
- Alarm symptoms indicate a need for further testing and include the following:
- Patients older than 50 years with a new onset of symptoms
- Hematochezia not associated with hemorrhoids or anal fissures
- Iron deficiency anemia
- Nightime diarrhea
- Unexpected weight loss
- Family history of inflammatory bowel disease (IBD), colon cancer, or celiac disease
- This guideline defines severe IBS-D as having more than one of the following symptoms: recurrent and acute abdominal pain, the need to defecate often or stool incontinence, and the inability to function in the usual manner because of IBS.
Recommendations
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- Eluxadoline is suggested at a dose of 100 mg twice daily.
- The dose may be decreased to 75 mg twice daily for persons with mild to moderate liver dysfunction, for those who are unable to tolerate the 100 mg dosing regimen, or for those who are currently on an OATP1B1 inhibitor.
- Eluxadoline is contraindicated for the following patients due to the risk of pancreatitis:
- Those who consume 3 or more alcoholic drinks per day
- Those who have had a cholecystectomy
- Those who have a history of Sphincter of Oddi disease, Sphincter of Oddi spasm, bile duct blockage, or severe liver dysfunction, or pancreatitis
- Rifaximin is suggested at a dose of 550 mg three times daily for 14 days.
- Treatment can be repeated up to two more times if symptoms return.
- Alosetron is suggested at a dose 0.5 mg twice daily for women with severe IBS-D and who are monitored with a risk-management protocol.
- If constipation occurs, alosetron should be stopped and, once symptoms resolve, restarted at the lower dose of 0.5 mg once daily.
- Should constipation occur again at the 0.5 mg daily dose, alosetron should be discontinued.
- AMer 4 weeks of alosetron 0.5 mg twice daily, the dosage may be increased to 1 mg twice daily if diarrhea continues.
- Should diarrhea continue after 4 weeks at the 1 mg twice daily dose, stop alosteron.
- Loperamide is suggested.
- Loperamide is FDA approved for traveler's diarrhea and acute and chronic diarrhea.
- Tricyclic antidepressants (TCAs) are suggested.
- Multiple TCAs (amitriptyline, desipramine, trimipramine, imipramine, and doxepine) have been researched for use in the treatment of IBS, and selection and dosing decisions should be based on the patient's presentation and made on a case-by-case basis.
- Selective serotonin reuptake inhibitors (SSRIs) are not suggested.
- Antispasmodic medications are suggested.
- In the United States only peppermint oil, hyoscine, and dicyclomine are available.
- The patient-provider relationship in treating IBS-D, including shared decision-making, is essential for the most beneficial outcomes.
Reference
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Lembo, A., et al. (2022). AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with diarrhea.
Gastroenterology,
163(1), 137–151.
doi.org/10.1053/j.gastro.2022.04.017