Pharmacological Management of IBS with Constipation & IBS with Diarrhea Guidelines
The American Gastroenterological Association (AGA) 2022Pharmacological Management of IBS guidelines were published as two separate guidelines to stratify the treatment recommendations for two of the IBS subtypes: IBS with diarrhea (IBS-D) and IBS with constipation (IBS-C). The chart below details the new medication treatment options seen in the 2022 IBS guidelines compared to the pharmacological treatment options seen in the 2014 IBS guidelines.
Irritable bowel syndrome (IBS) is a disorder with a prevalence of 4-10% in adults, with millions of people struggling everyday with their IBS symptoms. IBS causes patients a significant decrease in their quality of life with elevated risk of psychological comorbidities, causing them to miss school, miss work, have decreased productivity, develop food avoidance behaviors, avoid social situations and traveling, and just in general leaving IBS patients feeling like they’re missing out on life because of their IBS symptoms. So the treatment of IBS can be life-changing for patients and give them freedom from their IBS symptoms.
For IBS with diarrhea, also called IBS-D, it's reported that 30-40% of IBS patients have this subtype. In 2014, the AGA guidelines had recommendations for the use of rifaximin, alosetron, loperamide, as well as tricyclic antidepressants and antispasmodic medications, and recommendations against the use of SSRIs. In the new 2022 guidelines, rifaximin recommendations are updated to also include the use of rifaximin for retreatment in those who have relapsing symptoms after initial response to treatment with rifaximin. Also added to the 2022 IBS-D guideline is the new addition of the medication eluxadoline.
IBS with constipation, also called IBS-C is a subtype said to account for one-third of IBS cases. In 2014, the AGA guidelines gave recommendations for the use of linaclotide, lubiprostone, polyethylene glycol laxatives, as well as tricyclic antidepressants and antispasmodic medications, and recommendations against the use of SSRIs. New to the 2022 IBS-C guidelines are the medications tenapanor, tegaserod, and plecanatide.
| Medication | Indication | 2014 AGA Recommendations | 2022 AGA Recommendations | Additional Comments |
|---|---|---|---|---|
Alosetron | IBS-D | Conditional recommendation with moderate certainty of evidence | Unchanged from 2014 | Only approved for women with severe IBS-D under a risk-management program |
| Loperamide | IBS-D | Conditional recommendation with very low quality certainty of evidence | Unchanged from 2014 | |
| Eluxadoline | IBS-D | New to 2022 Guidelines: Conditional recommendation with moderate certainty of evidence | Contraindicated for those without a gallbladder and those who drink >3 alcoholic beverages a day | |
| Initial Treatment with Rifaximin | IBS-D | Conditional recommendation with moderate certainty of evidence | Unchanged from 2014 | |
| Retreatment with Rifaximin | IBS-D | New to 2022 Guidelines: Conditional recommendation with moderate certainty of evidence | Recommended for patients with reemergence of symptoms following successful initial treatment with rifaximin | |
| Linaclotide | IBS-C | Strong recommendation with high certainty in evidence of effects | Unchanged from 2014 | |
| Lubiprostone | IBS-C | Conditional recommendation with moderate certainty | Unchanged from 2014 | |
| Polyethylene Glycol laxatives | IBS-C | Conditional recommendation with low certainty of evidence | Unchanged from 2014 | |
| Tenapanor | IBS-C | New to 2022 Guidelines: Conditional recommendation with moderate certainty of evidence | ||
| Plecanatide | IBS-C | New to 2022 Guidelines: Conditional recommendation with a moderate certainty of evidence | Approved for women under 65 with no history of cardiovascular ischemic events | |
| Tegaserod | IBS-C | New to 2022 Guidelines: Conditional recommendation with moderate certainty | ||
| Tricyclic Antidepressants | IBS-C & IBS-D | Conditional recommendation with low certainty of evidence | Unchanged from 2014 | |
| Anti-spasmodics | IBS-C & IBS-D | Conditional recommendation with low certainty of evidence | Unchanged from 2014 | |
| SSRIs | IBS-C & IBS-D | Recommends AGAINST SSRIs, with a conditional recommendation and low certainty of evidence | Unchanged from 2014 |
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