IBS with Diarrhoea: Next Step After Loperamide Has Not Controlled Symptoms

Clinical Scenario

Irritable bowel syndrome with diarrhoea (IBS-D) is a recognised subtype, classified by the predominant loose or frequent stool pattern. Subgrouping patients by stool pattern — IBS-D, IBS-C, IBS-M, or IBS-U — is the basis for directing therapy.

First-Line Treatment — Goals Not Met

This protocol is indicated when a first-line trial of loperamide, with the dose titrated carefully to improve tolerability, has not achieved the target outcomes of improved stool frequency and improved stool consistency. Escalation to a licensed second-line approach in secondary care is the next step.

Second-Line Approach — Partial Overview

Second-line management in secondary care for IBS-D involves licensed agents from distinct drug classes — including a mixed opioid receptor-targeting option with specific contraindications — with the choice between them shaped by individual patient factors and local availability. The complete regimen and selection criteria are in the full protocol.

Treatment goals: improvement in abdominal pain and improvement in stool consistency.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1136/gutjnl-2021-324598

Patients are subgrouped according to their predominant stool pattern into IBS with diarrhoea (IBS-D), IBS with constipation (IBS-C), IBS with mixed bowel habits (IBS-M) or IBS unclassified (IBS-U), to direct therapy.
Eluxadoline, a mixed opioid receptor drug, is an efficacious second-line drug for IBS with diarrhoea in secondary care. It is contraindicated in patients with prior sphincter of Oddi problems or cholecystectomy, alcohol dependence, pancreatitis or severe liver impairment, and lack of availability may limit its use (recommendation: weak, quality of evidence: moderate).

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