Treatment Options and Management of IBS, IBS-D

In this podcast, Gregory Sayuk, MD, MPH, speaks about the different types of treatment options available for patients with irritable bowel syndrome (IBS) and irritable bowel syndrome with diarrhea (IBS-D), how clinicians can cater treatment strategies to their patients’ needs, and the future of IBS and IBS-D management. 

For more IBS-D content, visit the Resource Center. 

Additional Resources: 

• Sayuk GS. Medical therapies for diarrhea-predominant irritable bowel syndrome. Gastroenterol Clin N Am. 2021;50(3):611-637. doi:10.1016/j.gtc.2021.04.003. 

Gregory Sayuk, MD, MPH, is a gastroenterologist at Washington University in St. Louis, Missouri. 

TRANSCRIPTION:

Jessica Ganga: Hello, everyone and welcome to another installment of Podcasts360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Ganga, with Consultant360, a multidisciplinary medical information network.

IBS is one of the most common gastrointestinal disorders worldwide, affecting approximately 15 percent of the world's population, according to the National Institutes of Health. About 40 percent of patients with IBS experience symptoms of the subtype IBS-D.

Here with us today to talk about medical therapies for IBS-D is Dr Gregory Sayuk, who is a gastroenterologist at Washington University in St. Louis, Missouri. Thank you for joining us on the podcast today, Dr Sayuk. Let's dive right in. To start off, can you please provide an overview of your article, "Medical Therapies for Diarrhea-Predominant Irritable Bowel Syndrome?"

Dr Gregory Sayuk: Well, this was conceived as part of a broader series in the gastroenterology clinics of North America, that was really focusing on irritable bowel syndrome. And so here we were really attempting to try to provide, for clinicians, a current review of the available treatment options for irritable bowel syndrome, both FDA-approved options, as well as non-FDA-approved options. And even some of the other things that we sometimes will offer patients that have some evidence and support of their use, including supplements, for example, as well.

So we try to provide an overview, and then also try to provide some of the evidence and support of the use of these agents to manage our IBS-D symptoms for our patients.

Jessica Ganga: What is the importance of taking a careful history and examination in patients with symptoms of IBS-D?

Dr Sayuk: Right. Well, so the key here really is what I think most experts are now advocating for—which is a positive diagnostic strategy. And what we mean by this is that through the conduction of a thorough history, a physical exam, and really some very limited laboratory work, we can with a high level of confidence, establish a diagnosis of IBS, and accordingly then, proceed with the initiation of therapy. So I think one of the misconceptions with IBS is that it's a diagnosis of exclusion. That the clinician has to go through an extensive and exhaustive evaluation, including a lot of testing, such as imaging studies, extensive lab work, endoscopic evaluation, and so forth.

What our evidence and literature supports however, is that with a thorough history in the absence of the so-called red flag features or alarm symptoms here, we're talking about things such as blood in the stool. We're talking about weight loss, nocturnal symptoms, anemia, things of that sort. We can be very confident with a high degree of accuracy in our diagnosis of IBS. And so that's really why it's important to conduct a thorough history and physical and some basic lab work prior to making a diagnosis.

Jessica Ganga: A multidimensional approach is beneficial for managing patients with IBS-D. How should a patient with IBS-D be managed?

Dr Sayuk: That's a great question. So I think, unfortunately, we as physicians often rely heavily on pharmacotherapies for the management of disorders, including IBS-D, irritable bowel syndrome. And in reality, the most effective approach is a multimodal approach, an approach that implements strategies from a variety of different mechanisms. So certainly there's a major role for pharmacotherapy, and we're fortunate that we have an ever increasing number of options available to us to manage IBS symptoms. But there are other strategies that have equally good evidence in support of their use to help these patients, including psychological therapies, such as cognitive behavioral therapy and hypnotherapy, for example. Supplement and herbal therapies, so-called complimentary approaches. You have evidence and support of them. Even some lifestyle modifications, things like attention to sleep and exercise and so forth.

So when I see a patient with IBS, I ultimately hope to bring all of these things into the equation. I like to make the analogy with my patients that managing IBS is kind of like playing golf. You're not going to be a good golfer simply by having a great drive. You've got to be able to play all of the clubs in your bag, including your putter, if you want to be able to be an excellent golfer. And in a similar way, managing IBS relies on us to pull out all of these different options at times, sometimes using several of them in the same patient.

Jessica Ganga: There is a growing number of emerging therapies in this area. What are they, would you say?

Dr Sayuk: Well, this is really an exciting time for those of us who manage IBS regularly, and for our patients as well. Again, because we do have this increasing number of options available, and data, good evidence in support of using these adoptions. So from a pharmacotherapy perspective, over the last several years, we've had an emergence of the secretagogue agents. These have fallen under the class of the guanylate cyclase, or GCC agonists, such as linaclotide and plecanatide. But more recently, we've had a new class of agents, a sodium proton exchange blockade agent in tenapanor, which also is effective for the management of IBS here on the constipated side of things.

We also have increasing number of supplements that have good evidence in support of their use, including in the case of IBS-D things such as peppermint, which has now been studied in several different clinical trials and shown to be beneficial. Glutamine, also having shown benefit, potentially, in particular, in those patients that develop symptoms after an acute infection, or the so-called post infectious IBS-D patient. Bile acid sequestrants are a class that have gotten a lot of attention. Here, the notion being that patients with IBS-D, approximately a third of these individuals may actually have some bile acid malabsorption as part of the mechanism underlying their symptoms.

The gut microbiota has been an area of much interest of late. And so use of antibiotic strategies, use of probiotics and prebiotics all have been studied and are gaining additional momentum and demonstrated value in managing our IBS-D patients. So really, again, it's a very exciting time that we have all of these different strategies emerging. Whereas if you look back at the early phase of my career 20 years ago, we had very, very few options to offer our patients. So I think both as a provider and from a patient perspective, it's certainly a time to be optimistic about the future.

Jessica Ganga: Yeah. It sounds like there's a wide range of treatment options available to patients with IBS and IBS-D.

Dr Sayuk: Yeah, absolutely. And partly, I think it depends on the patient's experiences, what treatments they've tried in the past and what their responses to those treatments have been. But I also like to take the opportunity to explore what the patient's interests are. Some patients have more of a desire to try pharmacologic options, they're interested in medications. While others may be particularly focused on diet and lifestyle changes in an effort to manage their symptoms.

So I look at our portfolio of treatment options as a menu, and we review these with the patients, try to get a sense of what they're interested in trying. There's no single right answer for any particular patient, and there's equally, no one-size-fits-all approach. So it really does become an individualized strategy. And that's what I really like about treating these patients, is the fact that you do get to work with the patient in a collaborative way to try to get their symptoms under control.

Jessica Ganga: Speaking about the wide range of treatment options for patients with IBS-D, what would you say are the gaps in the research of IBS-D and its treatment, and what's next for research on this topic?

Dr Sayuk: Well, I think where we are right now with the management of IBS more generally, and certainly IBS-D, is the point where we're ready to, I think take the next step in trying to develop strategies, to develop therapeutic approaches that are based on biomarkers in the individual. So whereas previously we've really relied exclusively on symptoms to define the disorder, as we discussed earlier, make a diagnosis and proceed with treatment. I think we're now coming upon an era where we will be able to employ biomarkers. Things like profiles of the microbiota and the stool, things like genotypes and expression of neurotransmitter levels. And make then an educated, strategic decision about what mechanism may be driving that individual's symptoms. And also then to select the therapy, which we think will be more likely to positively influence that mechanism for that individual.

So this is, again, I think another area that's very exciting in our field. Is that over the next say, 10 years, I anticipate that we will be able to even improve outcomes with the existing therapies that we have available by just pairing the right therapy with that patient. So I think this is really an area of ongoing research, but also likely progress within the next decade.

Jessica Ganga: What would you say are the overall take home messages from our conversation today?

Dr Sayuk: I think the main points that I'd like to convey to the audience is that IBS is a diagnosis that is based in symptoms and limited evaluation. The ACG guidelines that were published just last year recommend the use of a positive diagnostic strategy to make that diagnosis and proceed with therapy beyond that. Again, underscoring the point that we have a multitude of different treatment strategies, both pharmacologic and non-pharmacologic. That this provides opportunities for our patients in a multimodal approach to managing their symptoms. And that with the application of these current available strategies, fortunately, we are able to improve symptoms and the quality of life of our patients in the majority of cases.

So again, I think the future is very bright in the field of DGBIs and irritable bowel syndrome. And I expect that we're going to continue to make great progress over the next decade with additional therapies, and moreover, the individualization of those therapies for our patients.

Jessica Ganga: Well, thank you, Dr Sayuk, for joining us today. Is there anything that you'd like to add that maybe I didn't ask about, or anything that we didn't cover?

Dr Sayuk: No, I don't think so, in particular. I think I would just point out that there are a lot of great organizations out there that provide additional information for providers and patients. The IFFGD, The International Foundation for GI Disorders, has some excellent resources for providers and patients both, as well as the Rome Foundation and the American Neurogastroenterology and Motility Societies. All of these organizations do excellent work in providing quality, evidence-based information for patients and providers, and are organizations that I'm proud to be a part of.

Jessica Ganga: Great, thank you for providing that additional information. And again, thank you for taking the time out of your day to speak with us.

Dr Sayuk: Thank you very much, Jessica.