IBS Treatments

There are many treatment approaches available for IBS. For most people, diet and lifestyle changes are the best option for long-term relief of symptoms.There are now many scientific studies that have shown the effectiveness of a FODMAP diet for IBS symptoms.

However, a range of other treatment options, including alternative therapies are available to treat IBS. These include:

  • Medications (such as anti-depressants, antibiotics, laxatives and anti-diarrheal medications)
  • Natural and herbal remedies (such as peppermint oil)
  • Nutritional supplements (such as fibre and probiotics)
  • Physical activity (such as yoga)
  • Psychological therapies (such cognitive behavioural therapy and hypnotherapy)
  • Speak to your healthcare provider for advice about which IBS treatments are right for you.

Medications

Antidepressants

Certain antidepressant medications are sometimes used in low doses to treat IBS. This is because they have side effects on the digestive tract that can be helpful with relieving symptoms. Some types inhibit the nervous system in the gut. These can be helpful for relieving pain and urgency if you have IBS with diarrhea (IBS-D). Others speed up the movements of the gut, so are more helpful for those with IBS with constipation (IBS-C).

Two classes are commonly prescribed - tricyclic antidepressants and selective serotonin-reuptake inhibitors (or SSRIs). A side effect of the tricyclic anti-depressants is constipation, so these are often used in people with IBS-D. By contrast, SSRIs may be more helpful in people suffering major depression and/or in people with IBS-C.(1) 

As with all medications, antidepressants can have side effects. It is important to work with your doctor to find a medication that works best for you.

Anti-spasmodics

Antispasmodics have been used to manage symptoms of IBS for many decades. This was based on the belief that smooth muscle spasms may trigger pain in people with IBS. These agents provide short-term relief in some people with IBS. However, side effects such as constipation, fatigue and dry mouth are possible.

Antibiotics

For some people with IBS, an overgrowth of bacteria in their small intestine may be the cause of symptoms. Treatment with the antibiotic Rifaxamin may be helpful in this case.

Your doctor may recommend a trial of Rifaxamin if you have IBS with bloating and diarrhea. In clinical studies, a 4 week treatment with Rifaxamin improved global symptoms of IBS in patients with IBS, but without constipation.(2)

Laxatives

Various types of laxative medications are available, but they all aim to help stimulate a bowel movement and relieve constipation. If you suffer from a GI disorder like IBS or inflammatory bowel disease, choice of laxative can be more important. This is because some types may actually worsen symptoms.

Two types of laxatives are typically used to manage constipation in IBS – osmotic and stimulant laxatives. Osmotic laxatives work by drawing water into the stool, resulting in softer stools and more frequent, easier to pass bowel motions.

Commonly used osmotic laxatives include polyethylene glycol (PEG), milk of magnesia and lactulose. PEG is often recommended to patients with IBS-C.(1)

Stimulant laxatives increase the contraction of muscles in the intestines, which helps to induce bowel movements. Examples of stimulant laxatives include senna, bisacodyl, castor oil, cascara, rhubarb, and aloe. Although these agents are sometimes used in IBS, there is little evidence to show they are effective. Talk to your doctor or pharmacist for more advice about laxative use.(1) 

Anti-diarrheal medications

These medications act on the bowel to slow down its movement. In this way they can be used to relieve diarrhea.

Natural and herbal remedies

Peppermint oil

Peppermint oil is one of the most well studied natural therapies in IBS. It appears to have natural properties that help to relax the smooth muscles of the gut. For someone with IBS the smooth muscle contractions can happen too often and be painful.

Studies suggest that the relaxing properties of peppermint oil may decrease pain and cramping associated with IBS.

It is important to choose peppermint oil capsules that are enteric coated. This reduces the risk of reflux.

Nutritional supplements

Fiber

Too much or not enough fiber can be problematic if you have irritable bowel syndrome (IBS). Fiber supplementation can be helpful in the treatment of IBS with diarrhoea and IBS with constipation. This is because fiber can add bulk to stools and regulate the amount of water they contain.

Like laxatives, there are many different types of fibers available, so choice of supplement is important. This is because some types may actually worsen symptoms if you have IBS. Increasing fibre intake through food choices first is always preferable, so working with a dietitian can be very helpful.

It is recommended that you eat 25-30g of dietary fiber every day. If you are unsure about how much fiber you are having, try keeping a food diary. You can then use an online fiber calculator to help estimate your intake.

Probiotics

Probiotics are live microorganisms that may help to improve the balance of healthy bacteria in the gut. Probiotics are available in the form of capsules, powders and liquids. They are also sometimes included in food products, such as yoghurts, fermented milk drinks and fermented foods.

Some studies have shown that probiotic supplements are safe and effective in IBS. However, we do not know enough from research to recommend particular strains and doses of probiotics for IBS. If you choose to try a probiotic supplement, it is recommended that you:

  • Take 1 probiotic supplement at a time and monitor your symptoms
  • Take the supplement for at least 4 weeks (benefits may take time to occur
  • Take the supplement regularly – benefits disappear when the therapy is stopped
  • Consider other ingredients – synbiotics (mixtures of prebiotics and probiotics) often contain FODMAPs, such as inulin or FOS. These may be poorly tolerated in people with IBS
  • Stop the therapy after 4 weeks if you experience no improvement in IBS symptoms

Physical activity

Exercise affects the function of our gastrointestinal tract. Generally speaking, these effects are positive, so doing some regular exercise is considered a useful strategy to reduce symptoms of IBS.(3)

The effects of exercise on gastrointestinal symptoms may depend on the intensity of exercise undertaken (sedentary, light/moderate or very strenuous).

For example, people who are very physically inactive may be more prone to constipation than more active individuals. At light to moderate levels, exercise may help constipated people to open their bowels more regularly. It can also help move gas through the gastrointestinal tract, and to reduce bloating.

On the other hand, exercise can worsen gastrointestinal symptoms. This is usually seen with very strenuous exercise, especially if this is undertaken in the heat and when dehydrated.(4)

Yoga

Several studies have now shown the benefits of yoga for relieving IBS symptoms. It is believed that this is due to yoga's combined use of breathing techniques, poses and meditation. This is thought to improve IBS symptoms through reducing stress levels, improving muscle relaxation and therefore improving digestive function.(5)

Psychological therapies

Stress and anxiety are thought to influence both the development of IBS and the onset of IBS symptoms. While this may seem surprising, researchers believe this occurs due to two-way communication that occurs between the brain and the gut. This communication pathway is known as the ‘brain-gut axis’.(6)

You may have experienced this communication when you felt ‘nervous butterflies’ before an exam or job interview. Research has also shown us that:

  • People who have suffered early life trauma (such as abuse) are more likely to suffer from IBS
  • Stress and anxiety are risk factors for the development of IBS
  • People with IBS are more likely to have a psychological disorder (and vica verca)
  • Stress and anxiety can trigger IBS symptoms in some people Severity of psychological symptoms is related to severity of IBS symptoms
  • Given the relationship between stress, anxiety and IBS, it is not surprising that research has shown that psychological therapies can effectively treat both psychological symptoms and physical symptoms of IBS.

Psychological therapies that may reduce symptoms of IBS include:(6)

  • Gut directed hypnotherapy
  • Mindfulness training
  • Stress management
  • Cognitive behavioural therapy

Medications that target psychological symptoms can also effectively treat IBS.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a common psychological therapy that is used to treat many health problems, but now also IBS. CBT aims to help people with IBS better understand how their thoughts and emotions may impact or worsen their symptoms.

Therapists then work with patients to implement practical strategies to manage unhelpful thoughts that would otherwise worsen IBS symptoms. Many high quality studies have shown that CBT is an effective IBS treatment, with long-term benefits.(6)

Gut-directed hypnotherapy

Gut-directed hypnotherapy is a special type of hypnotherapy. Gut-directed hypnotherapy requires patients to enter an altered consciousness or trance-like state. The gut-directed hypnotherapist then makes suggestions for the control and normalisation of gastrointestinal function.

For example, you may be asked to imagine yourself swallowing down a medicine known to improve gut function. You may then be instructed to imagine the medicine providing protection against your IBS symptoms, such as abdominal pain and diarrhoea. Research has shown that gut directed hypnotherapy is a safe and effective in approximately 70% of IBS patients.

A similar level of effectiveness is seen with some medications and a low FODMAP diet. If you are interested in trying gut directed hypnotherapy, ask your health professional for referral to a gut-directed hypnotherapist. It is important that the gut-directed hypnotherapist you choose has expertise in the area of gastroenterology and IBS.

References:

  1. Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. Jama. 2015;313(9):949-58.
  2. Li J, Zhu W, Liu W, Wu Y, Wu B. Rifaximin for Irritable Bowel Syndrome: A Meta-Analysis of Randomized Placebo-Controlled Trials. Medicine. 2016;95(4):e2534.
  3. Johannesson E, Simren M, Strid H, Bajor A, Sadik R. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. 2011;106(5):915-22.
  4. de Oliveira EP, Burini RC. The impact of physical exercise on the gastrointestinal tract. Curr Opin Clin Nutr Metab Care. 2009;12(5):533-8.
  5. Schumann D, Langhorst J, Dobos G, Cramer H. Randomised clinical trial: yoga vs a low-FODMAP diet in patients with irritable bowel syndrome. Aliment Pharmacol Ther. 2018;47(2):203-11.
  6. Ford AC, Quigley EM, Lacy BE, Lembo AJ, Saito YA, Schiller LR, et al. Effect of antidepressants and psychological therapies, including hypnotherapy, in irritable bowel syndrome: systematic review and meta-analysis. Am J Gastroenterol. 2014;109(9):1350-65; quiz 66.