Irritable Bowel Syndrome: Management

Key points

• Management is often difficult and varies between patients. NICE first-line pharmacological treatment is by predominant symptom.
• Pain: antispasmodic agents.
• Constipation: laxatives, but avoid lactulose (bloating). Diarrhoea: loperamide first-line.
• Refractory constipation: linaclotide if maximum-tolerated laxatives from different classes have not worked and constipation has persisted for 12 months.
• Diet/lifestyle: regular meals, adjust fibre (soluble e.g. ispaghula, not bran), limit caffeine/alcohol; a low-FODMAP diet (with a dietitian) helps some. Second-line: a low-dose tricyclic (amitriptyline), then an SSRI; consider CBT/psychological therapy for refractory symptoms.