This handout is for irritable bowel syndrome (rome iv; ibs-d / ibs-c / ibs-m / ibs-u; post-infectious ibs). Your care team identified this based on: recurrent abdominal pain related to defecation / bowel-habit change (rome iv positive-diagnosis trigger).
Other reasons your team may use this plan: chronic altered bowel habit — diarrhoea / constipation / mixed ± bloating (rome iv); existing ibs on problem list (subtype review / refractory-symptom visit) (acg 2021); new ibs-type symptoms following acute infectious enteritis — post-infectious ibs (klem 2017 pmid 28069350).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| patient_education_therapeutic_relationship | — | — | — | ACG 2021 — effective clinician-patient relationship improves outcomes; positive-diagnosis communication reduces unnecessary testing |
| soluble_fibre_psyllium | 3-4 g/day soluble (psyllium/ispaghula), titrate up | PO | daily | ACG 2021 strong recommendation — SOLUBLE (not insoluble) fibre improves global symptoms; NNT ~7 (Moayyedi meta-analysis) |
| dietitian_led_low_fodmap_with_reintroduction | 4-6 wk restriction → structured reintroduction → personalisation | dietary | staged | Black low-FODMAP network MA (Gut 2022 PMID 34376515) — RR global IBS symptoms not improving 0.67 (95% CI 0.48-0.91) vs habitual diet, ranked first; 13 RCTs n=944 (also Black 2021 PMID 33585949); MUST be dietitian-led with structured reintroduction to avoid nutritional/microbiome harm (BSG 2021) |
| physical_activity_sleep_optimisation | — | — | — | ACG 2021 / BSG 2021 — physical activity improves IBS symptoms; sleep hygiene supports gut-brain axis |
Plan: IBS subtype-directed therapy (ACG 2021 + AGA IBS-C/IBS-D 2022 + BSG 2021)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Mild disease: review at 4-8 weeks then as needed. Moderate-severe / refractory: structured follow-up q4-12 weeks during therapy escalation; reinforce diet reintroduction and self-management; post-infectious IBS — counsel on gradual improvement over months-years (Klem 2017 PMID 28069350). Reassess diagnosis if alarm features emerge or response is atypical; coordinate multidisciplinary care (dietitian, psychology). SPECIAL-POPULATION MATRIX (≥6): (1) PREGNANCY/LACTATION — diet/fibre/PEG first-line; loperamide short-term only (avoid 1st trimester); AVOID eluxadoline and alosetron (no safety data + SOD/ischaemic risk), AVOID rifaximin (animal teratogenicity), defer secretagogues (linaclotide/plecanatide pregnancy data limited; lubiprostone animal loss), TCA/SSRI only if benefit outweighs risk (TCAs assoc. worse fetal outcomes — not for IBS indication in pregnancy) (Medical Letter PMID 32324174; ACG 2021). (2) ELDERLY — TCAs (amitriptyline) and antimuscarinic antispasmodics (dicyclomine/hyoscyamine) on STOPP/Beers (anticholinergic burden, falls, urinary retention, delirium, constipation) — prefer secondary-amine nortriptyline/desipramine at low dose; constipation risk amplifies in IBS-C; tegaserod CONTRAINDICATED ≥65 yr (CV ischaemic risk) (STOPP v3 O'Mahony 2023; ACG 2021). (3) RENAL IMPAIRMENT — secretagogues minimally renally cleared but caution in severe CKD; rifaximin minimal systemic absorption (safe); recheck eGFR via calc.ckd_epi_2021 before TCA/SSRI dose escalation (KDIGO 2024). (4) HEPATIC IMPAIRMENT — eluxadoline CONTRAINDICATED in severe hepatic impairment (Child-Pugh C) and dose-reduce 75 mg in mild-moderate; rifaximin caution Child-Pugh C (↑systemic exposure); TCA/SSRI hepatic metabolism — start low (Lembo NEJM 2016 PMID 26789872; ACG 2021). (5) POST-INFECTIOUS SUBGROUP — distinct natural history (OR 4.2 [3.1-5.7] within 12 mo of enteritis, gradual resolution over months-years; usually IBS-D, female/antibiotic/anxiety risk factors) — counsel on prognosis, avoid over-investigation (Klem 2017 PMID 28069350). (6) PAEDIATRIC — distinct Rome IV PAEDIATRIC functional GI criteria; do NOT apply adult IBS pathway/pharmacology → route OUT to paediatric GI. (7) COMORBID PSYCHIATRIC — bidirectional gut-brain axis (anxiety/depression both predict and worsen IBS and PI-IBS); PHQ-9/GAD-7 at baseline + follow-up, gut-brain neuromodulator + psychological-therapy selection, safety-plan on positive PHQ-9 Q9 (ACG 2021; BSG 2021; Klem 2017) (ACG 2021; BSG 2021)
Guideline: ACG 2021 IBS Clinical Guideline (Lacy AJG 2021, PMID 33315591) + BSG 2021 IBS Guideline (Vasant Gut 2021, PMID 33903147) + AGA Clinical Practice Guideline IBS-C 2022 (PMID 35738724) + IBS-D 2022 (PMID 35738725) + Rome IV criteria; depth-pass-2 2026-05-17 added van Rheenen 2010 calprotectin diagnostic MA (PMID 20634346 — the LR+ ≈23.3 organic-disease rule-in), Black secretagogue/low-FODMAP network MAs, Menees rifaximin MA, Ingrosso peppermint-oil MA, Irvine coeliac-in-IBS MA, Garsed ondansetron RCT, Lembo/Cash eluxadoline pancreatitis safety