Believe it or not, roughly 20% of the population have irritable bowel syndrome (IBS). Of this, we see that about half the IBS patients at Ignite Nutrition fall under the umbrella of diarrhea-predominant irritable bowel syndrome (IBS-D) or have symptoms that alternate between diarrhea and constipation (IBS-M).
Diarrhea predominant IBS can be SO frustrating to manage. Loose stools cause urgency, which causes stress, which tends to make symptoms worse!
IBS-D Management – Our Approach
At Ignite, we first approach diarrhea management from 3 perspectives.
- how quick the gut moves (motility)
- stool consistency
- working on abdominal pain and cramping that is so common when your bowels tend to empty quickly!
Today we are going to be discussing exactly how we manage IBS-D, as well as discussing some non-pharmacological options. At Ignite, we say ‘food first, medication second’. There are times when medication management is of course, necessary, but first, we try to get symptoms under control with food, and non-pharmacological options.
What we see as a result of this is a decrease in total doses of medicine required, and typically better quality of life for our patients!
Today, this post is sponsored by Fowler’s Digestive. They’re a company passionate about supporting patients with IBS and digestive disorders with non-pharmacological treatment options. We have partnered with them because we have seen that their products bring symptom relief to patients when food isn’t quite enough!
First, let’s review common treatment options for IBS-D. They all fall into our four pillars of IBS management at Ignite, and may be addressed by your dietitian or gastroenterologist.
- Adequate dietary fibre (creates bulk in stool, absorbs excess water, and reduces sensation of urgency)
- Elimination of FODMAP foods in the diet (reduces the amount of water moving into the bowels and reduces fermentation in the gut)
- Limiting foods that increase motility such as fatty foods, spicy foods, and caffeine.
Stress Management Strategies:
Stress management is key in IBS management. It is important because our brain is constantly communicating with the gut and sometimes stress can alter the message! In IBS, patients often experience anxiety around their food choices or have stressors in other areas of their lives. Stressors can lead to perceived pain in the gut, as well as altered gut motility. Some management strategies for stress include:
- Cognitive Behavioural Therapy
- Working on food & body trust
Here are some examples of the most common medicines we see used to manage IBS-D.
- Loperamide (slows bowels down)
- Antispasmodics (reduces perception of pain and relaxes muscles in the gut)
- Antidepressants (reduces perception of pain)
- Rifaximin (reduces bacterial overgrowth in the bowel)
- Eluxadoline (slows bowels down and reduce abdominal pain)
Many times, we see patients prescribed medication first. This may be appropriate depending on the severity of your IBS. But it is important to ask: how effective are these? What is the safety? And is there an alternative I should consider first?
At Ignite Nutrition, we aim to take a food-first approach to IBS, meaning we prioritize dietary management strategies first. This does not mean pharmacological options are considered “bad” or unnecessary, but rather that we explore them later in the management process, and occasionally, will suggest them earlier on if IBS symptoms are severe.
Challenges of Pharmacotherapy
Although medication is often necessary for those with IBS-D, it does not come without challenges and potential risks. In fact, a recent review from Lacy et al. explored the risks and benefits of pharmacotherapy in IBS-D. One medicine that caught our attention, and is often used by our patients as it’s available over the counter, is loperamide.
This drug belongs to a category of drugs called opioid receptor agonists. It’s role is to slow contractions in the gut and alter the movement of water and electrolytes in the bowel. It is often used as an emergency therapy for acute diarrhea but has become more routine in the symptom management of IBS-D, with many patients taking it daily, and understandably so. With urgency and a fear of incontinence, it’s no wonder patients rely on it to get them through flights, drives, meetings and more.
Although effective for many, it is important to understand the risks – especially if you have cardiac issues or a history of pancreatitis – as side effects have been shown to exacerbate both conditions, especially if used in larger doses or more frequently.
What we see as the more common issue with loperamide is that it causes constipation, making it seem like your bowels are on a never ending rollercoaster.
This doesn’t mean that you shouldn’t take loperamide or that you need to panic – but what we think it brings to attention is a) can we reduce its use through proper management strategies and b) can we choose a more benign option, with less side effects and similar outcomes?
This is one out of manymedications used in the management of IBS-D. The take-away from this example is that ALL medications should be re-evaluated regularly to determine safety and efficacy.
If dietary management strategies are inadequate for patients, we next consider non-pharmacological options. These are a great stepping stone between food and medications, especially in patients that have mild symptoms or situational flare-ups in diarrhea and other IBS symptoms.
One brand we’re proud to work with is Fowler’s Digestive Health. Fowler’s has been a long-standing name in the digestive healthcare industry. What sets them apart is that they strive to make safe products that don’t disrupt the body’s natural rhythms, like some medications do. In particular, Fowler’s offers two products for the management of IBS-D as non-pharmacological options:
Anti-diarrheal Oral Suspension
This formula consists of attapulgite, a magnesium aluminum phyllosilicate. Attapulgite helps to bind water and bacteria in the digestive tract, creating more solid stool in those with both acute or chronic diarrhea.
Attapulgite is non-systemic, meaning it doesn’t get absorbed into the bloodstream, keeping it isolated to the digestive tract until it is excreted.
In a comparison study between attapulgite and loperamide, attapulgite did significantly improve stool consistency. Loperamide did act more quickly, however, at 48 hours, patients self-reported that the overall relief in symptoms was equivalent. This shows us that there are safe and effective non-pharmacological choices we can utilize prior to adding or increasing medications.
What we see in practice is patients choosing to take loperamide in anticipation of an episode of diarrhea, ie. for airplane flights or long drives, rather than traditionally for acute diarrhea – so in this case, using the Fowler’s anti-diarrheal oral suspension slightly sooner could be used to prevent situational diarrhea.
I don’t usually share too deeply into the day-to-day management of IBS, but it gives this story some important context. I tend to dismiss my N=1 when its personal, but I think it provides valuable insight into how I can best help patients, living with the condition myself!
When I first decided to try Fowlers Digestive Tonic, I was skeptical (as someone with not only IBS but issues with reflux – I expected liquid peppermint might not be the best for me). However, it quickly became my absolute favorite tool in my IBS management arsenal when I had symptom flare ups from stress, or eating too many FODMAP’s. It’s because of my positive experience that I wanted to work with them! (Now I just have to convince them to make a TSA travel-size approved bottle)
Fowler’s Digestive Tonic includes a combination of peppermint oil and silicon. This natural remedy provides soothing relief from various symptoms of IBS including gas, bloating, and abdominal pain.
Peppermint acts as both an antispasmodic and an anti-inflammatory agent, relaxing the smooth muscles of the gastrointestinal tract and creating an overall sense of ‘calm’ in our IBS’ers guts. It’s really no surprise this herb has become a leader in gut health, as it’s been used as a digestive aid for centuries!
The research on peppermint oil has yielded some promising results in IBS patients. A meta-analysis conducted in 2014 concluded that peppermint oil was two times more likely to improve overall IBS symptoms than a placebo.5More specific to diarrhea, additional studies have also shown that peppermint oil has reduced stool frequency in those with IBS.6
How we see our patients use Fowler’s Digestive Tonic:
- Patients take it when they are noticing their digestive symptoms worsen
- If they plan to consume something that might bother their stomach
- If they’re having a flare up in symptoms – for whatever reason! Changes in hormonal cycle, stress, sleep, and nutrition can cause fluctuations in symptoms.
The Take-Away About IBS-D Management
- Medication management is not benign – we, as health professionals, are responsible for keeping our patients safe. It is especially important to evaluate and re-evaluate medications prior to and during patient use. This applies not only to IBS-D but other gastrointestinal diseases and beyond!
- If food and lifestyle management is not providing ideal results, consider non-pharmacological options. Natural digestive aids such as those from Fowler’s are a great ‘stepping stone’ between dietary management of IBS and pharmacological strategies. They provide gentle relief in comparison to some other medications on the market for IBS-D today.
- Fowler’s anti-diarrheal oral suspension and Digestive Tonic are both great options for everyday use, but also work great as a ‘rescue therapy’ during times when flare-ups are more likely. For example, when travelling, experiencing changes in diet, or after a period of antibiotic use.
Need Help With Your IBS?
If you need help managing your digestive disorder or are looking for dietitian support to coordinate care with your health care providers on your medication management – we’re happy to help! Work with one of our dietitians today.
Disclosure: This is a sponsored post. I was compensated for my time in writing this post. While the information conveyed may support clients’ objectives, the opinions expressed are my own and based on current scientific evidence. I do not engage in business with companies whose products or services do not match my personal and professional beliefs.
- Drugbank.ca. (2018). Loperamide – DrugBank. [online] Available at: https://www.drugbank.ca/drugs/DB00836 [Accessed 16 Oct. 2018].
- Lacy BE. Review article: an analysis of safety profiles of the treatments for diarrhoea‐predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2018;00:1–14. https://doi.org/10.1111/apt.14948
- Drugbank.ca. (2018). Attapulgite – DrugBank. [online] Available at: https://www.drugbank.ca/drugs/DB01574 [Accessed 16 Oct. 2018].
- DuPont HL, Ericsson CD, DuPont MW, Cruz LA, Mathewson JJ. A randomized, open-label comparison of non-prescription loperamide and attapulgite in the symptomatic treatment of acute diarrhea. Am J Med. 1990 Jun; 88(6A):20S-23S
- Khanna R, MacDonald JK, Levesque BG. Peppermint oil for the treatment of irritable bowel syndrome: a systematic review and meta-analysis. J Clin Gastroenterol. 2014 Jul;48(6):505-12.
- Shams R, Oldfield EC, Copare J, Johnson DA. Peppermint Oil: Clinical Uses in the Treatment of Gastrointestinal Diseases. JSM Gas-troenterol Hepatol 2015 Jan;3(1): 1036.2