Irritable bowel syndrome

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

Dietary and lifestyle advice

Give information explaining the importance of self-help in effectively managing IBS. Include information on general lifestyle, physical activity, diet and symptom-targeted medication.

• Encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time.

• Assess the person’s physical activity levels (ideally using the General Practice Physical Activity Questionnaire). Give brief advice and counselling to people with low activity levels to encourage them to increase their activity levels.

Assess the person’s diet and nutrition, and give the following general advice:

• Have regular meals and take time to eat. Avoid missing meals or leaving long gaps between eating

• Drink at least 8 cups of fluid per day (especially water or other non-caffeinated drinks, e.g., herbal teas). Restrict tea and coffee to 3 cups per day, and reduce intake of alcohol and fizzy drinks

• It may be helpful to limit intake of high-fibre food (e.g., wholemeal or high-fibre flour and breads, cereals high in bran, whole grains such as brown rice)

• Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), which is often found in processed or re-cooked foods

• Limit fresh fruit to 3 portions per day (a portion should be approximately 80 g)

• People with diarrhoea should avoid sorbitol (an artificial sweetener found in sugar-free sweets [including chewing gum] and drinks, and in some diabetic and slimming products)

• People with wind and bloating may find it helpful to eat oats (e.g., oat-based breakfast cereal or porridge) and linseeds (up to 1 tablespoon per day).

Review the person’s fibre intake, adjusting (usually reducing) it while monitoring the effect on symptoms. Discourage people with IBS from eating insoluble fibre (e.g., bran).

• If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (e.g., oats).

Advise people with IBS who choose to try probiotics to take the product for at least 4 weeks (at the dose recommended by the manufacturer) while monitoring the effect.

Discourage the use of aloe vera in the treatment of IBS.

If IBS symptoms persist while following general lifestyle and dietary advice, advice on further dietary management should be offered. Such advice should:

• Include single food avoidance and exclusion diets (e.g., low FODMAP [fermentable oligosaccharides, disaccharides, monosaccharides and polyols] diet)

• Only be given by a healthcare professional with expertise in dietary management.

Pharmacological therapy

Base decisions about pharmacological management on nature and severity of symptoms. The choice of single or combination medication is determined by the predominant symptom(s).

Consider prescribing antispasmodic agents to be taken alongside diet and lifestyle advice.

For the treatment of constipation, consider:

• Laxatives, but discourage the use of lactulose

• Linaclotide, only if optimal or maximum tolerated doses of previous laxatives from different classes have not helped and the person has had constipation for at least 12 months

  • Follow up people taking linaclotide after 3 months.

Loperamide should be the first choice of antimotility agent for diarrhoea.

Advise how to adjust doses of laxative or antimotility agent according to clinical response.

• The dose should be titrated according to stool consistency, with the aim of achieving a soft, well-formed stool (corresponding to Bristol Stool Form Scale type 4).

Consider tricyclic antidepressants as second-line treatment for IBS if laxatives, loperamide or antispasmodics have not helped. Start at a low dose and review regularly.

Consider selective serotonin-reuptake inhibitors for IBS only if tricyclic antidepressants are ineffective.

Consider possible side effects when offering tricyclic antidepressants or selective serotonin-reuptake inhibitors. Follow up people taking either of these drugs for the first time at low doses to treat IBS pain or discomfort after 4 weeks and then every 6 to 12 months.

Other interventions

Consider referral for psychological interventions (cognitive behavioural therapy, hypnotherapy and/or psychological therapy) for people who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (described as refractory IBS).

Do not encourage the use of acupuncture or reflexology for the treatment of IBS.

Follow-up

Agree follow-up with the person, based on the response of their symptoms to interventions. This should form part of the annual patient review.

• If any 'red flag' symptoms emerge during management and follow-up, ensure they are investigated further and/or refer to secondary care.

© NICE (2017) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.