Version July 2025
5-HT3: 5-hydroxytryptamine 3; IBS: irritable bowel syndrome.
* IBS subtypes are dynamic, and the assignment of an incorrect subtype may result in treatment that exacerbates symptoms. Therefore, we review the patient's symptoms and stool diary at every visit and when making treatment changes to confirm treatment is tailored to the appropriate IBS subtype.
¶ Global IBS symptoms include abdominal pain, bloating, and cramping. Treatment for persistent global IBS symptoms despite subtype-specific treatment is discussed separately. Refer to related UpToDate content for additional details.
Δ Loperamide may also be given prophylactically for identified symptom triggers (eg, exercise, stressful situations). For patients with alternating diarrhea and constipation, use should be limited to short courses due to the risk of exacerbating constipation.
◊ Bile acid sequestrants are optimally dosed at the time of bile acid release. If the patient has a gallbladder, we give bile acid sequestrants in conjunction with meals. If the patient does not have a gallbladder, we give the bile acid sequestrant in between meals and separated from other medications by at least 2 hours.
§ We reserve alosetron for patients with severe symptoms refractory to loperamide and at least 1 bile acid sequestrant due to the risk of serious adverse effects (eg, ischemic colitis). Use requires exclusion of gastrointestinal tract abnormalities. Refer to UpToDate content for additional details.
¥ We reserve eluxadoline for selected patients with severe symptoms that are refractory to all other agents as it is associated with a high incidence of severe acute pancreatitis. Refer to UpToDate content for additional details.
