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Irritable bowel syndrome: What can help?

Last Update: August 1, 2013.

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There are a lot of treatments that aim to relieve the symptoms of irritable bowel syndrome – but not all of them have been tested in high-quality studies. Because the causes of IBS are not clear, it is difficult to find suitable treatments. But research has suggested that at least some medications and treatments may be helpful.

Abdominal pain, constipation and diarrhea are the main symptoms of irritable bowel syndrome (IBS). Most people only have mild symptoms that they can cope with fairly well without treatment. Over time they learn to understand their body's signals. But sometimes the symptoms are so strong that they significantly affect people’s everyday lives and cause distress. Then several different treatment options can be considered.

The latest research on treatments for IBS

First of all, it is important to mention that many of the studies on IBS treatments are of limited quality. Because they often only lasted a few weeks, it is not clear how long the treatment effects last, or whether the treatments still offer relief when used for a longer time. Also, there is not enough research on most of these treatments to be able to say whether the type or severity of symptoms play a role in the treatment. For example, people who have more diarrhea might benefit more from some treatments, and those who have more constipation might benefit more from other treatments. This has not been properly accounted for in many studies. But research has indicated what treatments might be worth trying out - as well as which of them are the best tolerated and safest.

Can extra fiber help?

People with IBS are often advised to eat more fiber. There are two different types of dietary fiber:

  • Soluble fiber, which absorbs water in the bowel (e.g. psyllium, also called isphagula)
  •  Insoluble fiber, which hardly absorbs any water (e.g. bran)

Psyllium and bran are the two best studied dietary fibers. Bran has not been shown to relieve IBS symptoms in studies - it even seems to make some people's symptoms worse. Research suggests that psyllium might help about 1 out of 10 people.

Can dietary supplements relieve the symptoms?

Peppermint oil

Many people take peppermint oil products to relieve their symptoms. Peppermint oil is believed to relax the bowel muscles.

Several studies have indeed shown that some people benefit from peppermint oil, at least temporarily: it relieves IBS symptoms in about 4 out of 10 people. In these studies, peppermint oil was taken in capsules that are resistant to stomach acid. The dose that people took was between 500 and 800 mg per day. It is not clear whether taking peppermint oil in other forms, such as solutions or drops, can help. Only a few participants reported having side effects, but the side effects of peppermint oil were not considered in all of the studies.

Probiotics

Gut flora contains different types of bacteria that play an important role in the intestine. These include lactic acid bacteria (LAB) and bifidobacteria. Some people with IBS have abnormal gut flora, so it is thought that probiotics might be able to help.

Some studies suggest that probiotics might help against IBS. They were shown to reduce symptoms in about 1 to 2 out of 10 people. More research is needed to be able to say which type of bacteria and which doses help the most. Probiotics are generally well tolerated. But they can sometimes lead to infections in people who have a weakened immune system.

What medications are effective for IBS?

Anti-cramping medications

People who are mostly affected by cramps often use anti-cramping medications. These are meant to relax the bowel muscles to relieve the pain caused by the cramps. Anti-cramping medications are also called antispasmodics or spasmolytics. Many of these medications have not been studied enough in the treatment of IBS. But research suggests that at least four of the medications may help: butylscopolamine, cimetropium, pinaverium and otilonium. The antispasmodic mebeverine, often prescribed in Germany, has not been proven to help against IBS because there are not enough available research results.

You can find more information on this topic in our feature.

Of the anti-cramping medications that have been shown to help, only butylscopolamine is available in Germany. Studies found that this medication relieved IBS symptoms in 1 to 2 out of 10 people. Butylscopolamine is available in pharmacies without a prescription in Germany.

The possible side effects of anti-cramping medications include a dry mouth, dizziness and blurred vision. About 5 out of 100 people in studies reported these types of side effects. There were no serious side effects.

Medications for constipation or diarrhea
Medications for constipation or diarrhea can also be used, depending on which of these symptoms is more of a problem. But there is hardly any research on how well these medications can relieve IBS symptoms. Many laxatives and anti-diarrhea medications are available in pharmacies without a prescription.

One disadvantage of these medications is that they might just replace one problem with another: a medication for diarrhea may cause constipation if its effect is too strong. In the same way, a medication for relieving constipation can lead to diarrhea. It is important to make sure the medications do not make the symptoms even worse, especially in people who have alternating diarrhea and constipation.

Antibiotics
Antibiotics are sometimes considered as a treatment option for people whose IBS causes diarrhea or flatulence. The best studied antibiotic is called rifaximin. In Germany, this drug is only approved for the treatment of travelers’ diarrhea. Yet doctors can still prescribe it “off-label” if they thoroughly inform their patient. Off-label use means that a drug is used to treat a condition without being approved for that specific use. If you are prescribed a drug off-label, you will usually have to pay for it out of your own pocket. You can read more about this in our information on off-label use.

In studies, rifaximin was shown to relieve IBS symptoms in about 1 out of 10 people. But it is not clear whether it also has a positive effect in the long term. According to current recommendations, antibiotics should not be used too often because they can have various side effects, including allergic reactions, nausea and fungal infections. Also, improper use or overuse of antibiotics can also contribute to bacteria becoming resistant to antibiotics, meaning that they will not be as effective in the future.

Antidepressants

Sometimes IBS is treated with drugs that are normally used to treat depression. These include so-called tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). These drugs are only available on prescription. In Germany, they are not approved for treating IBS, so they can only be used off-label.

There are different reasons why it is thought that certain antidepressants may help in IBS. For instance, some of these drugs are said to have a pain-relieving effect. Some also influence the muscles of the digestive tract.

Research has shown that tricyclic antidepressants and SSRIs can help relieve IBS. Symptoms improved in about 2 out of 10 people who took one of these drugs. But antidepressants can have various adverse effects too, such as loss of appetite, nausea, and problems with sexual arousal and orgasm. So they are generally only considered if other therapies have not been successful. Some antidepressants can themselves lead to constipation or diarrhea.

Other drugs

Some 5-HT3 and 5-HT4 antagonists have been approved for the treatment of IBS in several countries. These drugs include alosetron and cilansetron, which have mostly been tested for the treatment of IBS with diarrhea, and tegaserod, which has mostly been tested for the treatment of IBS with constipation. These drugs have been shown to relieve IBS symptoms in about 1 to 2 out of 10 people. But alosetron and cilansetron cause constipation in 2 out of 10 people. Tegaserod sometimes causes diarrhea.

These drugs have not been approved in Germany. There are safety concerns because they are associated with serious side effects such as heart attacks, strokes and vascular disorders of the bowel.

There is also another 5-HT4 antagonist called prucalopride. Its use in the treatment of chronic constipation in women was approved in Germany in 2009, but only in those who have already tried conventional laxatives and found that they did not help. Because prucalopride has not been on the market for long, not much is known about possible side effects and the long-term safety of this drug.

How effective are acupuncture, reflexology and enemas?

Other approaches used to treat IBS include acupuncture, reflexology and enemas (also called colon hydrotherapy).

Many people say that they feel better after having acupuncture. But a number of studies have shown that this is not due to the specific effects of acupuncture: it was not more effective than a "fake" treatment.

There is very little scientific research on reflexology and enemas as treatments for IBS. So it is not clear whether they are effective. This is a reason for caution, particularly with enemas: they are associated with serious complications such as electrolyte imbalances, infections, bowel injuries or even perforations.

Are psychological treatments or hypnosis also an option?

Because it is suspected that psychological stress may contribute to the development of IBS, relaxation techniques and strategies for coping with stress are sometimes used. But there is not enough research to show whether these things can help people with IBS.

Psychotherapy approaches such as cognitive behavioral therapy are used to treat IBS too. The aim of this kind of treatment is to help people learn how to better cope with the symptoms of IBS. Some of these treatments require a lot of time and motivation. There is some weak evidence that cognitive behavioral therapy may offer at least short-term relief in people with IBS. You can read more in our feature on cognitive behavioral therapy.

Some people who have IBS try hypnotherapy. During hypnosis sessions, therapists help people focus very intensely and solely on one thing, so that they stop being aware of other things. The idea is that they are then more receptive to suggestions the therapist makes. For the treatment of IBS, an example of such a suggestion is imagining that you have a healthy, well-functioning bowel. Research has indicated that hypnotherapy can relieve symptoms in some people.

Published by the Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

Next planned update: August 2016. You can find out more about how our health information is updated in our text "Informed Health Online: How our information is produced." 

References

  • IQWiG health information is based on research in the international literature. We identify the most scientifically reliable knowledge currently available, particularly what are known as “systematic reviews.” These summarize and analyze the results of scientific research on the benefits and harms of treatments and other health care interventions. This helps medical professionals and people who are affected by the medical condition to weigh up the pros and cons. You can read more about systematic reviews and why these can provide the most trustworthy evidence about the state of knowledge in our information “Evidence-based medicine.” We also have our health information reviewed to ensure medical and scientific accuracy.
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