Irritable bowel syndrome
ICD-10 K58 · ICD-11 DD91.0

IBS Symptoms Persisting After a Low-FODMAP Diet — The Recommended Next Step

For patients with irritable bowel syndrome (IBS) whose global symptoms and abdominal pain have not adequately improved after completing a properly supervised dietary programme, an evidence-based pharmacological protocol is available as the next step.

Prior treatment & the reason for escalation

A low-FODMAP diet — implemented as a second-line dietary therapy under the supervision of a trained dietitian, with FODMAPs reintroduced according to individual tolerance — is the preceding intervention. When this approach fails to achieve meaningful improvement in global IBS symptoms and abdominal pain, the protocol described here becomes indicated.

Next-line approach (overview)

This protocol centres on a gut-brain neuromodulator — a pharmacological class that acts on the gut-brain axis relevant to IBS. Which specific agent is selected, and under what clinical circumstances an alternative within this class is preferred, is detailed in the full structured regimen.

Treatment goal

Improvement in global IBS symptoms and abdominal pain.

Instant Access to Structured Evidence-Based Regimens

References

Tricyclic antidepressants used as gut-brain neuromodulators are an effective second-line drug for global symptoms and abdominal pain in IBS. They can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side-effect profile. They should be commenced at a low dose and titrated slowly (recommendation: strong, quality of evidence: moderate).

TCAs should be taken in the evening, before bedtime, due to their sedating effects, and may also improve sleep patterns.

Selective serotonin reuptake inhibitors used as gut-brain neuromodulators may be an effective second-line drug for global symptoms in IBS. As with tricyclic antidepressants, they can be initiated in primary or secondary care, but careful explanation as to the rationale for their use is required, and patients should be counselled about their side-effect profile (recommendation: weak, quality of evidence: low).

DOI: 10.1136/gutjnl-2021-324598

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