Treatments for IBS
Guidelines for an IBS Diagnosis Leading to Treatment
A clear and accurate IBS diagnosis is helpful in guiding and evaluating treatments for GI symptoms. Knowing why patients have IBS is the key to knowing how to treat it. In the past, IBS was a diagnosis of exclusion, meaning that IBS was diagnosed based on ruling other diseases out.
With an antibody blood test, IBS can finally be ruled in, allowing patients to access the right treatment quickly. The ACG Clinical Guidelines for Management of Irritable Bowel Syndrome support this strategy, as it suggests "a positive diagnostic strategy" (ruling in IBS) as compared to "a diagnostic strategy of exclusion" (ruling out other diseases) "... to improve time to initiate appropriate therapy... and to improve cost-effectiveness."
There are clear, evidence-based guidelines for IBS treatment in the American College of Gastroenterology’s Clinical Guidelines for the Management of IBS.
Recommended Treatments for IBS
From medication to lifestyle changes, finding what works for each patient can often be a journey. After a positive IBS diagnosis can be determined with an antibody blood test, the ACG Clinical Guidelines for Management of IBS recommend the following options for treating global IBS symptoms:
A limited trial of the Low FODMAP Diet: Highly fermentable foods are filled with short chain carbohydrates that don’t get fully absorbed by the small intestine and, in turn, start to ferment in the colon, exacerbating IBS symptoms. The Low FODMAP Diet is a three-phase diet designed to help you eliminate, reintroduce, and avoid foods with these types of carbohydrates.
Low Fermentation Eating: Low Fermentation Eating (LFE) supports a more balanced microbiome by decreasing the amount of the fermented foods in a patient's diet.
Soluble, but not insoluble, fiber: Dietary fiber has many effects on the microbiome and is commonly recommended for patients with IBS with minimal risk of any side effects. Dietary fiber can improve stool viscosity and frequency as well.
Peppermint oil: Peppermint oil is a natural herbal remedy for IBS symptoms. Peppermint oil aids in muscle relaxation in your gut and can also have visceral, antimicrobial, and anti-inflammatory effects. Peppermint oil is usually well received by patients; however, there are some patients who feel a heartburn effect.
Rifaximin: Many IBS patients benefit from the use of FDA-approved antibiotics like Rifaximin. Rifaximin is known for its safe effect on improving symptoms in the microbiome with no additional bacterial resistance.
The Low FODMAP Diet for IBS Treatment
The most common diet doctors discuss for their IBS patients is called the Low FODMAP Diet. The Low FODMAP Diet is a food category diet based on research conducted at Monash University, one of Australia's leading public research universities. Researchers at Monash have found that up to 75% of people with IBS feel better on the Low FODMAP Diet during the elimination phase.
Fermentable - The process of bacteria in the gut fermenting unabsorbed carbohydrates into gas
Oligosaccharides (Fructans) - Found in foods such as wheat, rye, onions, garlic, and legumes/pulses
Disaccharides (Lactose) - Found in dairy products like milk, soft cheeses, and yogurts
Monosaccharides (Fructose) - Found in honey, apples, and high-fructose corn syrups
Polyols (Sorbitol and Mannitol) - Found in some fruits and vegetables and used as artificial sweeteners
In the first phase of the Low FODMAP Diet, the patient eliminates all highly fermentable foods from their diet for 2-6 weeks. In the second phase which lasts 8-12 weeks, the patient slowly reintroduces fermentable foods one at a time. This allows the patient to identify the exact foods that could be contributing to their IBS symptoms.
In the final phase, patients will have a better understanding of which foods they should avoid and consume and can then integrate this change into their daily lifestyle, hopefully leading to less intrusive IBS symptoms.
Here is some more information on diet manipulation for IBS treatment.
Low Fermentation Eating (LFE) for IBS Treatment
Low Fermentation Eating (LFE) supports a more balanced microbiome by decreasing the amount of the fermented foods in a patient's diet. Developed by Mark Pimentel, MD and Ali Rezaie, MD, LFE is specifically designed for those patients suffering from SIBO and IBS symptoms like bloating, gas, constipation, and diarrhea.
Low Fermentation Eating is based on two parts: restricting foods with high carbohydrates and meal timing. When carbohydrates cannot be properly broken down, the bacteria in the gut then digest the sugars, releasing gases like hydrogen, methane, and hydrogen sulfide that can result in frustrating GI symptoms. Additionally, spacing out meal times with four to five hours between consumption allows for gut-cleaning waves.
Non-absorbable common sugar substitutes like sucralose, sorbitol, lactitol, xylitol, mannitol, and stevia are some of the top foods to avoid, because they cannot be digested by humans and instead feed the bacteria in the gut directly. High-fiber foods and foods with inulin, a type of prebiotic, are also considered troublesome. Foods like lentils, beans, soy products, and dairy products like milk, cheese, and yogurt are considered “fermentable” foods, as they can be difficult to digest and excessively feed the bacteria in the gastrointestinal tract. They should be avoided, as well.
The gut is self-cleaning, and it’s very important not to disrupt these natural gut-cleaning waves with food digestion. The gut-cleaning waves cannot occur until fasting. The feeding part of digestion ends within three hours of eating, and it’s suggested to have two gut-cleaning cycles before eating again. That means that leaving four to five hours between meals can support a more regular and proper cleaning cycle.
To learn more about Low Fermentation Eating (LFE) and get tasty recipes, please visit thegoodlfe.com.
Additional Treatments for IBS
While there are common diets and recommendations a doctor might consider when working with an IBS patient, the ACG Guidelines offer a few other, perhaps lesser known, treatments for IBS.
Alosetron is a medication for women to help treat the common symptoms of IBS including diarrhea, bloat, pain, and urgency. This medication should only be used for those women who have failed conventional therapy for their IBS symptoms.
Mixed Opioid Agonists/Antagonists are medications with moderate to strong analgesic effects depending on the opioid receptor and dose.
Chloride Channel and Guanylate Cyclase Activators are medications that increase fluid in the intestines, allowing stool to pass through more easily. This treatment is used to treat those with constipation-based IBS (IBS-C).
Tricyclic Antidepressants are unique because of their atomic structure consisting of three rings of atoms. A tricyclic antidepressant is a medication used to treat depression.
Gut-Directed Psychotherapies are types of conventional and hypnotic therapies addressing the communication and miscommunication between the gut and mind. This technique helps relax the mind and consequently the gut.
Treatments Not Recommended for IBS
A positive diagnosis for IBS is helpful to guide patients on the right path of treatment; however, it can also be helpful in guiding patients on which treatments to avoid. The ACG Guidelines suggest against the following for treatments for global IBS symptoms:
Antispasmodics are drugs to treat muscle spasms. The ACG Guidelines recommend against antispasmodics, because the data available is outdated and of poor quality.
Probiotics are living microorganisms that are commonly used to restore gut flora. Probiotics are not recommended for treating global IBS symptoms, because the existing literature contains small studies of numerous strains of probiotics and shows inconsistent benefits.
Bile acid sequestrates are medications used to lower cholesterol usually combined with diet modification. The ACG Guidelines do not recommend bile acid sequestrates because of the lack of validated and reliable studies.
Fecal transplant is a procedure in which a patient receives stool from a healthy donor in order to treat a GI condition. A fecal transplant is not a recommended treatment for IBS, because evidence of efficacy of treatment is limited and of very low quality. Additional research is also needed to determine which is the most effective type of donor.
The Value of an IBS Diagnosis for the Treatment of IBS
A positive result on an antibody blood test for IBS can indicate that a change in diet, lifestyle, medication, or therapy could be effective in relieving your symptoms. An IBS diagnosis can also confirm you are on the right treatment plan and provide the motivation to comply with your lifestyle change as you start to feel better.
An antibody blood test for IBS measures the levels of two antibodies that are IBS biomarkers: anti-CdtB and anti-vinculin. If these antibodies are elevated, IBS can be diagnosed with up to 100% positive predictive value. This diagnosis can also help you avoid potentially unnecessary tests and procedures that simply rule out other diseases.
With your antibody results, your doctor can develop a personalized treatment plan that targets your microbiome, combining medication, lifestyle, and dietary changes so that you can start feeling healthy as quickly as possible.
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