British Society of Gastroenterology lays down updated guidelines on managing IBS

The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based management of patients. For the guidelines, the research team searched MEDLINE, EMBASE, EMBASE Classic and the Cochrane central register of controlled trials between January 2017 and September 2020.

The key highlights are given below.

Doctor-patient communication

1. Establishing an effective doctor-patient relationship and a shared understanding is key to the management of IBS. Such a relationship can lead to improved quality of life and symptoms, reduce healthcare visits and enhance adherence to treatment (recommendation: strong, quality of evidence: low).
2. Patients with IBS would like increased empathy, support and information from clinicians about the nature of the condition, diagnosis and symptom management options (recommendation: strong, quality of evidence: low).

Diagnosis, investigation and education

1. The National Institute for Health and Care Excellence guideline definition of IBS (abdominal pain or discomfort, in association with altered bowel habit, for at least 6 months, in the absence of alarm symptoms or signs) is more pragmatic and may be more applicable to patients with IBS in primary care than diagnostic criteria derived from patients in secondary care, such as the Rome IV criteria (recommendation: weak, quality of evidence: low).
2. All patients presenting with symptoms of IBS for the first time in primary care should have a full blood count, C reactive protein or erythrocyte sedimentation rate, coeliac serology and, in patients <45 years of age with diarrhoea, a faecal calprotectin to exclude inflammatory bowel disease. Local and national guidelines for colorectal and ovarian cancer screening should be followed, where indicated (recommendation: strong, quality of evidence: moderate).
3. Clinicians should make a positive diagnosis of IBS based on symptoms, in the absence of alarm symptoms or signs, and abnormalities on simple blood and stool tests (recommendation: strong, quality of evidence: moderate).
4. Referral to gastroenterology in secondary care is warranted where there is diagnostic doubt, in patients with symptoms that are severe, or refractory to first-line treatments, or where the individual patient requests a specialist opinion (recommendation: weak, quality of evidence: low).
5. There is no role for colonoscopy in IBS, other than in those with alarm symptoms or signs, or those with symptoms suggestive of IBS with diarrhoea who have atypical features and/or relevant risk factors that increase the likelihood of them having microscopic colitis (female sex, age ≥50 years, coexistent autoimmune disease, nocturnal or severe, watery, diarrhoea, duration of diarrhoea <12 months, weight loss or use of potential precipitating drugs including non-steroidal anti-inflammatory drugs, proton pump inhibitors, etc) (recommendation: strong, quality of evidence: moderate).
6. In those with symptoms suggestive of IBS with diarrhoea, but with atypical features such as nocturnal diarrhoea, or a prior cholecystectomy, 23-seleno-25-homotaurocholic acid scanning or serum 7α-hydroxy-4-cholesten-3-one should be considered to exclude bile acid diarrhoea (recommendation: strong, quality of evidence: low).
7. In patients with IBS and coexisting symptoms suggestive of a defaecatory disorder or faecal incontinence, anorectal physiology tests can be considered, where available, to select those who might benefit from biofeedback (recommendation: weak, quality of evidence: low).
8. There is no role for testing for exocrine pancreatic insufficiency, or for hydrogen breath testing to rule out small intestinal bacterial overgrowth or carbohydrate intolerance, in patients with typical IBS symptoms (recommendation: strong, quality of evidence: weak).
9. The diagnosis of IBS, its underlying pathophysiology and the natural history of the condition, including common symptom triggers, should be explained to the patient. This should introduce the concept of IBS as a disorder of gut-brain interaction, together with a simple account of the gut-brain axis and how this is impacted by diet, stress, cognitive, behavioural and emotional responses to symptoms, and postinfective changes (recommendation: strong, quality of evidence: weak).

First-line treatments

• All patients with IBS should be advised to take regular exercise (recommendation: strong, quality of evidence: weak).
• First-line dietary advice should be offered to all patients with IBS (recommendation: strong, quality of evidence: weak).
• Food elimination diets based on IgG antibodies are not recommended in patients with IBS (recommendation: strong, quality of evidence: moderate).
• Soluble fibre, such as ispaghula, is an effective treatment for global symptoms and abdominal pain in IBS, but insoluble fibre (eg, wheat bran) should be avoided as it may exacerbate symptoms. Soluble fibre should be commenced at a low dose (3–4 g/day) and built up gradually to avoid bloating (recommendation: strong; quality of evidence: moderate).
• A diet low in fermentable oligosaccharides, disaccharides and monosaccharides and polyols, as a second-line dietary therapy, is an effective treatment for global symptoms and abdominal pain in IBS, but its implementation should be supervised by a trained dietitian and fermentable oligosaccharides, disaccharides and monosaccharides and polyols should be reintroduced according to tolerance (recommendation: weak, quality of evidence very low).
• A gluten-free diet is not recommended in IBS (recommendation: weak, quality of evidence very low).
• Probiotics, as a group, may be an effective treatment for global symptoms and abdominal pain in IBS, but it is not possible to recommend a specific species or strain. It is reasonable to advise patients wishing to try probiotics to take them for up to 12 weeks, and to discontinue them if there is no improvement in symptoms (recommendation: weak, quality of evidence: very low).
• Loperamide may be an effective treatment for diarrhoea in IBS. However, abdominal pain, bloating, nausea and constipation are common, and may limit tolerability. Titrating the dose carefully may avoid this (recommendation: strong; quality of evidence: very low).
• Certain antispasmodics may be an effective treatment for global symptoms and abdominal pain in IBS. Dry mouth, visual disturbance and dizziness are common side effects (recommendation: weak, quality of evidence: very low).
• Peppermint oil may be an effective treatment for global symptoms and abdominal pain in IBS. Gastro-oesophageal reflux is a common side effect (recommendation: weak, quality of evidence: very low).
• Polyethylene glycol may be an effective treatment for constipation in IBS. Abdominal pain is a common side effect (recommendation: weak; quality of evidence: very low).

Second-line treatments

• Tricyclic antidepressants used as gut-brain neuromodulators are an effective second-line drug for global symptoms and abdominal pain in IBS. They can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side-effect profile. They should be commenced at a low dose (eg, 10 mg amitriptyline once a day) and titrated slowly to a maximum of 30–50 mg once a day (recommendation: strong, quality of evidence: moderate).
• Selective serotonin reuptake inhibitors used as gut-brain neuromodulators may be an effective second-line drug for global symptoms in IBS. As with tricyclic antidepressants, they can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side-effect profile (recommendation: weak, quality of evidence: low).
• Eluxadoline, a mixed opioid receptor drug, is an efficacious second-line drug for IBS with diarrhoea in secondary care. It is contraindicated in patients with prior sphincter of Oddi problems or cholecystectomy, alcohol dependence, pancreatitis or severe liver impairment, and lack of availability may limit its use (recommendation: weak, quality of evidence: moderate).
• 5-Hydroxytryptamine 3 receptor antagonists are efficacious second-line drugs for IBS with diarrhoea in secondary care. Alosetron and ramosetron are unavailable in many countries; ondansetron titrated from a dose of 4 mg once a day to a maximum of 8 mg three times a day is a reasonable alternative. Constipation is the most common side effect. This drug class is likely the most efficacious for IBS with diarrhoea (recommendation: weak, quality of evidence: moderate to high).
• The non-absorbable antibiotic rifaximin is an efficacious second-line drug for IBS with diarrhoea in secondary care, although its effect on abdominal pain is limited. The drug is licensed for IBS with diarrhoea in the USA but is not available for this indication in many countries (recommendation: weak, quality of evidence: moderate).
• Linaclotide, a guanylate cyclase-C agonist, is an efficacious second-line drug for IBS with constipation in secondary care. It is likely to be the most efficacious secretagogue available for IBS with constipation, although diarrhoea is a common side effect (recommendation: strong, quality of evidence: high).
• Lubiprostone, a chloride channel activator, is an efficacious second-line drug for IBS with constipation in secondary care. This secretagogue is less likely to cause diarrhoea than others. However, patients should be warned that nausea is a frequent side effect (recommendation: strong, quality of evidence: moderate).
• Plecanatide, another guanylate cyclase-C agonist, is an efficacious second-line drug for IBS with constipation in secondary care. Diarrhoea is a common side effect and is no less likely than with linaclotide or tenapanor. Although the drug is licensed for IBS with constipation in the USA, it is not yet available for this indication in many countries (recommendation: strong, quality of evidence: high).
• Tenapanor, a sodium-hydrogen exchange inhibitor, is an efficacious second-line drug for IBS with constipation in secondary care. Again, diarrhoea is a frequent side effect. Although the drug is licensed for IBS with constipation in the USA, it is not yet available for this indication in many countries (recommendation: strong, quality of evidence: high).
• Tegaserod, a 5-Hydroxytryptamine 4 receptor agonist, is an efficacious second-line drug for IBS with constipation in secondary care but is unavailable outside the USA. Diarrhoea is a common side effect (recommendation: strong, quality of evidence: moderate).

Psychological therapies

• IBS-specific cognitive behavioural therapy may be an efficacious treatment for global symptoms in IBS (recommendation: strong, quality of evidence: low).
• Gut-directed hypnotherapy may be an efficacious treatment for global symptoms in IBS (recommendation: strong, quality of evidence: low).
• Psychological therapies should be considered when symptoms have not improved after 12 months of drug treatment. Referral can be made at an earlier stage, if accessible locally, and based on patient preference (recommendation: strong, quality of evidence: low).

Management of severe or refractory IBS

• Severe or refractory IBS symptoms should prompt a review of the diagnosis, with consideration of further targeted investigation (recommendation: weak, evidence: very low).
• Severe or refractory IBS should be managed with an integrated multi-disciplinary approach (recommendation: weak, evidence: very low).
• Iatrogenic harms due to opioid prescribing, unnecessary surgery and unproven unregulated diagnostic or therapeutic approaches incentivised by financial or reputational gain should be avoided (recommendation: strong, evidence: very low).
• Use of combination gut-brain neuromodulators, termed augmentation, may be considered for more severe symptoms, with vigilance for risks of serotonin syndrome (recommendation: weak, evidence: very low).

"One of the strengths of this guideline is that the recommendations for treatment are based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of trial-based and network meta-analyses assessing the efficacy of dietary, pharmacological and psychological therapies in treating IBS."

For full article follow the link: http://dx.doi.org/10.1136/gutjnl-2021-324598

Primary source: Gut