Treatment of Irritable Bowel Syndrome - December 15, 2005 -- American Family Physician
Using an algorithm adapted from a New England Journal of Medicine article, a recent review in AFP promotes a multi factorial approach to the treatment of Irritable Bowel Syndrome (IBS). In addition to relaxation, stress reduction, education, and exercise, patients with mild IBS usually respond to dicyclomine (an antispasmodic) and peppermint. Patients with constipation do especially well with the addition of guar gum, fiber, exercise, and/or laxatives. Those who suffer from diarrhea or pain usually respond to the addition of immodium and TCAs (tricyclic antidepressants). Other treatments, including, 5-HT3 antagonists (Alosetron), 5-HT4 agonists (Tegaserod, or Zelnorm), Cisapride, probiotics, or cognitive-behavioral therapy, can be tried if other therapies fail.
Peppermint is especially interesting because it works well in several ways. It is an antispasmodic, anesthetic, and relieves nausea. As an herbal, it can be given over the counter or as a tea. Importantly, it may be acceptable to many patients who are hesitant to start a new 'medication'.
For those with constipation, guar gum is interesting for much the same reason as pepperment. It too can be given over the counter, and, importantly, patients tend to actually like it better than fiber.
Patients with diarrhea have two very good choices. We all know immodium, but it is important to know that it does suprisingly well in the treatment of IBS. In addition, TCAs such as desipramine (my favorate), amitryptyline, and clomipramine, work very well in low doses. Patients should know that the mechanism of action for TCA's is likely seperate from that which is involved in the antidepressant quality of the drugs (and thus you are NOT saying that they are crazy when prescribing the medication).
In short, patients with IBS have no reason to go untreated. There exist multiple good therapies, and good understanding and treatment of the illness is achievable.