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©2013 UpToDate ® Print Email 2009 American College of Gastroenterology (ACG) recommendations for the treatment of irritable bowel syndrome (IBS) Diet and irritable bowel syndrome Patients often believe that certain foods exacerbate their IBS symptoms. There is, however, insufficient evidence that food allergy testing or exclusion diets are efficacious in IBS and their routine use outside of a clinical trial is not recommended. Effectiveness of dietary fiber, bulking agents, and laxatives in the management of irritable bowel syndrome Psyllium hydrophilic mucilloid (ispaghula husk) is moderately effective and can be given a conditional recommendation. A single study reported improvement with calcium polycarbophil. Wheat bran or corn bran is no more effective than placebo in the relief of global symptoms of IBS and cannot be recommended for routine use. Polyethylene glycol (PEG) laxative was shown to improve stool frequency - but not abdominal pain - in one small sequential study in adolescents with IBS-C. Effectiveness of antispasmodic agents, including peppermint oil, in the management of irritable bowel syndrome Certain antispasmodics (hyoscine, cimetropium, pinaverium, and peppermint oil) may provide short-term relief of abdominal pain / discomfort in IBS. Evidence for long-term efficacy is not available. Evidence for safety and tolerability is limited. Effectiveness of antidiarrheals in the management of irritable bowel syndrome The antidiarrheal agent loperamide is not more effective than placebo at reducing pain, bloating, or global symptoms of IBS, but it is an effective agent for the treatment of diarrhea, reducing stool frequency, and improving stool consistency. Randomized controlled trials comparing loperamide with other antidiarrheal agents have not been performed. Safety and tolerability data on loperamide are lacking. Effectiveness of antibiotics in the management of irritable bowel syndrome A short-term course of a nonabsorbable antibiotic is more effective than placebo for global improvement of IBS and for bloating. There are no data available to support the long-term safety and effectiveness of nonabsorbable antibiotics for the management of IBS symptoms. Effectiveness of probiotics in the management of irritable bowel syndrome

A short-term course of a nonabsorbable antibiotic is more effective than placebo for global improvement of IBS and for bloating. There are no data available to support the long-term safety and effectiveness of nonabsorbable antibiotics for the management of IBS symptoms. Effectiveness of probiotics in the management of irritable bowel syndrome In single organism studies, lactobacilli do not appear effective for patients with IBS; bifidobacteria and certain combinations of probiotics demonstrate some efficacy. Effectiveness of the 5-HT 3 receptor antagonists in the management of irritable bowel syndrome The 5-HT 3 receptor antagonist alosetron is more effective than placebo at relieving global IBS symptoms in male and female IBS patients with diarrhea. Potentially serious side effects including constipation and colon ischemia occur more commonly in patients treated with alosetron compared with placebo. The benefits and harms balance for alosetron is most favorable in women with severe IBS and diarrhea who have not responded to conventional therapies. The quality of evidence for efficacy of 5-HT 3 antagonists in IBS is high. Effectiveness of 5-HT 4 (serotonin) receptor agonists in the management of irritable bowel syndrome The 5-HT 4 receptor agonist tegaserod is more effective than placebo at relieving global IBS symptoms in female IBS-C patients and IBS-M patients. The most common side effect of tegaserod is diarrhea. A small number (0.11 percent) of cardiovascular events (myocardial infarction, unstable angina, or stroke) were reported among patients who had received tegaserod in clinical trials. Effectiveness of the selective C-2 chloride channel activators in the management of irritable bowel syndrome Lubiprostone in a dose of 8 micrograms twice daily is more effective than placebo in relieving global IBS symptoms in women with IBS-C. Effectiveness of antidepressant agents in the management of irritable bowel syndrome Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are more effective than placebo at relieving global IBS symptoms, and appear to reduce abdominal pain. There are limited data on the safety and tolerability of these agents in patients with IBS. Effectiveness of psychological therapies in the management of irritable bowel syndrome

Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are more effective than placebo at relieving global IBS symptoms, and appear to reduce abdominal pain. There are limited data on the safety and tolerability of these agents in patients with IBS. Effectiveness of psychological therapies in the management of irritable bowel syndrome Psychological therapies, including cognitive therapy, dynamic psychotherapy, and hypnotherapy, but not relaxation therapy, are more effective than usual care in relieving global symptoms of IBS. Effectiveness of herbal therapies and acupuncture in the management of irritable bowel syndrome Available randomized controlled trials mostly tested unique Chinese herbal mixtures, and appeared to show a benefit. It is not possible to combine these studies into a meaningful meta-analysis, however, and overall, any benefit of Chinese herbal therapy in IBS continues to potentially be confounded by the variable components used and their purity. Also, there are significant concerns about toxicity, especially liver failure, with use of any Chinese herbal mixture. A systematic review of trials of acupuncture was inconclusive because of heterogeneous outcomes. Further work is needed before any recommendations on acupuncture or herbal therapy can be made. IBS: irritable bowel syndrome; IBS-C: constipation-predominant irritable bowel syndrome; IBS-M: mixed irritable bowel syndrome; 5-HT 3 : 5-hydroxytryptamine (serotonin) 3 receptor agonists; 5-HT 4 : 5-hydroxytryptamine (serotonin) 4 receptor agonists. Data from: American College of Gastroenterology IBS Task Force. An Evidence-Based Position Statement on the Management of Irritable Bowel Syndrome. Am J Gastroenterol 2009; 104:S1.