Treatment Options for Irritable Bowel Syndrome in Adults

Good communication, dietary and lifestyle advice: clear explanation and patient-centred discussion of IBS including:
• social/lifestyle factors: diet, exercise, sleep, and ingestion of caffeine, alcohol and other medication BDA IBS Food Fact Sheet
• psychological factors: presence of stress, anxiety, low mood and history of eating disorders
• biological factors: physiological abnormalities and medication side effects which are contributing to symptoms
1st Line Options 2nd Line Options

Antispasmodics - with dietary and lifestyle Antimotility Laxatives/soluble fibre

advice
1st Choice – hyoscine butylbromide 10mg to
20mg three times a day or peppermint oil
The evidence for effectiveness of mebeverine or
alverine in IBS is weaker than for hyoscine
butylbromide but may be better tolerated
Caution: Colpermin® contains arachis oil
Immediate release mebevrine is as effective as
modified release and lower cost
Note: Antimuscarinics which reduce intestinal
motility, such as hyoscine butylbromide and
dicycloverine are poorly selective and are more
likely to cause antimuscarinic adverse effects (dry
eyes and a dry mouth and can worsen
constipation) than direct-acting smooth muscle
relaxants or peppermint oil.
Dicycloverine is not recommended for
prescribing as it is poorly selective, more likely to
cause antimuscarinic adverse effects and there
are lower cost alternatives with relatively fewer
adverse effects
Refer to the prescribing guidance on
anticholinergic drugs for advice on side effects
(Adjust to clinical response)
1st Choice – Loperamide- licensed for
symptomatic treatment of acute episodes of
diarrhoea associated with IBS in adults.
Loperamide- dose of 4 mg initially, followed
by 2 mg after every loose stool, up to a
maximum of 12 mg per day, for diarrhoea-
predominant irritable bowel syndrome.
Liquid preparation helpful to those
requiring low doses as they are very
sensitive to the effects of loperamide
Advise people to adjust the dose of
loperamide according to clinical response.
The aim is to produce a soft, well-formed
stool.
Probiotics: if the patient wishes to try
probiotics, advise them to choose and self-
purchase one brand and take the
recommended dose for at least 4 weeks
but discontinue if no benefit after 8 weeks
(Adjust to clinical response)
Avoid lactulose, can worsen bloating
Consider bulk forming laxatives,
increase dose gradually e.g. Fybogel®
Flatulence and bloating are the most
common adverse effects of bulk-
forming laxatives. They can usually be
avoided or reduced by increasing the
dose of the laxative gradually every few
days until ONE or TWO soft formed
stools are produced every 1-2 days
An adequate fluid intake is important
to prevent intestinal obstruction.
Bulk-forming laxatives should not be
taken immediately before going to bed.
Consider adding or switching to
Macrogol compound oral powder
sachets or bisacodyl
If laxatives, loperamide or
antispasmodics have not helped,
consider tricyclic antidepressants as
2nd Line.
1ST Choice – Tricyclic Antidepressants
(TCA)
E.g. amitriptyline
(Unlicensed indication)
Start at a low dose e.g. 5mg to 10mg
amitriptyline, which should be taken
once at night and reviewed regularly.
The dose may be increased but should
not usually need to exceed 30 mg a day.
If TCAs have been shown to be
ineffective, are contraindicated,
or are not tolerated.
2nd Choice - Selective serotonin reuptake
inhibitors (SSRIs) - Citalopram, fluoxetine,
and paroxetine -unlicensed indication.

Patients with IBS-C (IBS with Constipation) that have failed a SIX month trial of at least two laxatives from different classes at
optimal/maximum tolerated doses may be suitable for a trial of linaclotide – refer to gastroenterology via CRS with a full laxative ▪ Citalopram: 10 mg to 20 mg daily.
history for the specialist to initiate a trial. ▪ Fluoxetine: 20 mg daily.
If beneficial, Specialist will recommend in writing to the GP to continue the prescribing ▪ Paroxetine: 10 mg to 20 mg daily

Produced by PMOT, WECCG and updated in collaboration with the Gastroenterology department at PAH Approved by MOPB December 2019, updated April 2022, review April 2025 or before if new guidance is published