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AGA proposes first pharmacologic treatment plan for patients with IBS-C, IBS-D

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The AGA has issued clinical guidelines that outline a pharmacologic treatment plan for patients with irritable bowel syndrome and its subtypes, IBS-constipation and IBS-diarrhea, which were published in Gastroenterology..

For the first time, these guidelines offer recommendations on when to use newly introduced drugs, when to rely on FDA-approved drugs and when over-the-counter drugs may be suitable. The guidelines also provide a framework for tailoring treatment approaches to patients’ specific symptoms.


AGA's irritable bowel syndrome pharmacologic treatment plan: “Benefits” – IBS-C; 1. First-line treatment: Osmotic laxatives and antispasmodics for mild symptoms, 2. Second-line: Secretagogues for moderate symptoms, 3. Third-line: Tegaserod for severe symptoms; “Risks” – IBS-D; 1. First-line treatment: Loperamide, bile acid sequestrants and antispasmodics for mild symptoms, 2. Second-line: Rifaximin, low-dose tricyclic antidepressants and eluxadoline for moderate symptoms, 3. Third-line: Alosetron for severe symptoms



“We have so many treatment options, we can now take a targeted treatment approach to patient symptoms,” Shahnaz Sultan, MD, AGAF,, Associate professor of medicine at the University of Minnesota and chair of the AGA clinical guidelines committee, said in an AGA press release. “It’s very important for patients to be open about their IBS symptoms and just as important for gastroenterologists to set realistic expectations for this chronic disease to ensure the best quality of life for their IBS patients. ”

The overarching advice for patients with IBS is to prioritize lifestyle modifications, including exercise, sleep and stress management, and dietary changes such as increasing fiber intake or adopting a low-FODMAP diet, prior to seeking advanced treatment from a GI specialist.

New clinical guidelines for pharmacologic treatment are:

IBS-C

  • For first-line treatment of patients with IBS-C experiencing mild constipation and abdominal pain, experts recommend osmotic laxatives, like polyethylene glycol, and antispasmodics such as hyoscyamine and peppermint oil.
  • For second-line treatment of moderate symptoms, experts recommend secretagogues such as linaclotide, lubiprostone, plecanatide and tenapanor.
  • Third-line recommendations include treatment with tegaserod.

IBS-D

  • For first-line treatment of patients with IBS-D experiencing mild diarrhea and abdominal pain, experts recommend loperamide, a bile acid sequestrant (eg, colestipol) and antispasmodics such as hyoscyamine and peppermint oil.
  • For second-line treatment of moderate symptoms, experts recommend rifaximin; low-dose tricyclic antidepressants, such as amitriptyline and desipramine; and eluxadoline.
  • Third-line recommendations for patients with IBS-D experiencing severe symptoms include treatment with alosetron.

For both subtypes, experts further recommend low-dose tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors and brain-gut behavioral therapies if abdominal pain and / or psychological symptoms persist.

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