Management of Irritable Bowel Syndrome (IBS): 2019 CAG Guideline

Canadian Association of Gastroenterology, CAG has released its 2019 guidelines on Management of Irritable Bowel Syndrome (IBS). The clinical practice guideline has appeared in Journal of the Canadian Association of Gastroenterology.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal (GI) disorders, affecting about 10% of the general population globally.

This Canadian consensus group consisted of 12 voting participants with experience in the area of IBS, including the chair (PM), gastroenterologists, general practitioners, a psychiatrist, a psychologist, a patient representative, and the moderator (also a gastroenterologist, WP). The aim of this consensus was to develop guidelines for the management of IBS.

Following are the major recommendations:

DIAGNOSTIC TESTING FOR IBS

• We suggest IBS patients have serological testing to exclude celiac disease.


• We recommend AGAINST testing for CRP in IBS patients to exclude inflammatory disorders.


• We recommend AGAINST routine testing for faecal calprotectin in IBS patients to exclude inflammatory disorders.


• We recommend AGAINST IBS patients <50 years of age without alarm features ROUTINELY having a colonoscopy to exclude alternate diagnoses.


• We suggest AGAINST IBS patients <50 years of age with alarm features ROUTINELY having a colonoscopy to exclude alternate diagnoses.


• We recommend patients with new-onset IBS symptoms at ≥50 years of age have a colonoscopy to exclude alternative diagnoses.


• We recommend AGAINST IBS patients having food allergy testing to identify triggers of IBS symptoms.


• We recommend AGAINST the routine use of lactose hydrogen breath tests in evaluating IBS patients.


• We recommend AGAINST the routine use of glucose hydrogen breath tests in evaluating IBS patients.

DIETARY MODIFICATIONS AND ALTERNATIVE THERAPIES FOR IBS

• We suggest offering IBS patients a low FODMAP diet to reduce IBS symptoms.


• We suggest AGAINST offering IBS patients a gluten-free diet to reduce IBS symptoms.


• We suggest AGAINST offering IBS patients wheat bran supplementation to improve IBS symptoms.


• We recommend offering IBS patients psyllium supplementation to improve IBS symptoms.


• We suggest AGAINST offering herbal remedies to IBS patients to improve IBS symptoms.


• We recommend AGAINST offering acupuncture to IBS patients to improve IBS symptoms.


• We suggest offering IBS patients peppermint oil to improve IBS symptoms.


• We suggest offering IBS patients probiotics to improve IBS symptoms.

PSYCHOLOGICAL THERAPIES FOR IBS

• We suggest offering IBS patients cognitive behavioural therapy to improve IBS symptoms.


• We suggest offering IBS patients hypnotherapy to improve IBS symptoms.

PHARMACOLOGICAL THERAPIES FOR IBS

• We suggest offering IBS patients certain antispasmodics (such as dicyclomine, hyoscine, pinaverium) to improve IBS symptoms.


• We recommend offering IBS patients low-dose tricyclic antidepressants to improve IBS symptoms.


• We suggest offering IBS patients SSRIs to improve IBS symptoms.


• We suggest AGAINST offering diarrhoea-predominant IBS patients continuous loperamide use to improve IBS symptoms.


• We suggest AGAINST offering diarrhoea-predominant IBS patients cholestyramine to improve IBS symptoms.


• We suggest offering diarrhoea-predominant IBS patients eluxadoline to improve IBS symptoms.


• We suggest AGAINST offering constipation-predominant IBS patients osmotic laxatives to improve OVERALL IBS symptoms.


• We suggest AGAINST offering constipation-predominant IBS patients prucalopride to improve OVERALL IBS symptoms.


• We suggest offering constipation-predominant IBS patients lubiprostone to improve IBS symptoms.


• We recommend offering constipation-predominant IBS patients linaclotide to improve IBS symptoms.

STATEMENTS WITH NO RECOMMENDATIONS

No recommendation A: The consensus group does not make a recommendation (neither for nor against) offering IBS patients relaxation techniques to improve IBS symptoms.
No recommendation B: The consensus group does not make a recommendation (neither for nor against) offering IBS patients short-term psychodynamic psychotherapy to improve IBS symptoms.
No recommendation C: The consensus group does not make a recommendation (neither for nor against) offering diarrhoea-predominant IBS patients one course of rifaximin therapy to improve IBS symptoms.