What pain killer is best for IBS?

IBS Diagnosis, Treatment and COVID-19

IBS (irritable bowel syndrome) is functional disorder of the gastrointestinal tract, meaning it is caused by a problem with the way the gastrointestinal tract works. It usually affects the lower GI area, which includes the small intestine, large intestine, and colon.

Patient with IBS typically do not have any signs of damage or disease in the intestinal tract damage, but rather suffer from a constellation of symptoms that occur together such as repeated pain in the abdomen, changes in bowel movements, feeling gassy, bloated, chronic diarrhea, constipation and, in some cases, both.

Estimates suggest that IBS affects between 25 and 45 million people in the United States, approximately 10 to 15 percent of the population. More women than men are impacted by IBS though it can affect anybody, including children. The most common onset age, however, is between 20 – 30 years old.

“While IBS can cause significant distress and discomfort to those affected, people do not typically experience severe complications as a result of the condition or a need for surgery,” said Andrew Sable, MD of Gastro Health – Florida. “Successful treatment depends on a close and on-going relationship with your physician as well as lifestyle and dietary changes and the use of medications.”

Diagnosing IBS

The American Gastroenterological Association notes that the underlying cause of IBS remains unknown, though it is believed there are several factors that can cause it.

“One such factor is dysmotility, a condition characterized by poor regulation of the muscle contracts of the GI tract,” said Nader Balba, MD of Gastro Health – Virginia. “Sensitivity of the nerves attached to the GI tract can be another potential cause of IBS.”

Because the symptoms of IBS are similar to those of other intestinal illnesses, diagnosis of IBS relies heavily on excluding other conditions first. In general, abdominal pain and other symptoms that recur at least one day per week, for a period of 12 weeks or longer with no other identifiable cause, tends to be diagnosed as IBS.

“What’s most important to understand though,” continued Dr. Balba, “is that IBS is a chronic, but manageable condition.”

IBS and COVID-19

The COVID-19 virus has been shown to impact the gastrointestinal tract including a growing body of evidence connecting gut microbiota and COVID-19 severity. A decent number of patients hospitalized with COVID-19 have been documented to also have diarrhea, nausea, and vomiting.

A recent study also found that COVID-19 has the potential to further influence symptoms in individuals with IBS and comorbid anxiety and/or depression. Individuals in the study reported increased stress (92%), anxiety (81%) and depressive symptoms (67%). In addition, half of the sample reported increases in abdominal pain (48%), diarrhea (45%), or constipation (44%).

The psychological stress caused by COVID-19, therefore, appears to increase the gastrointestinal symptoms in individuals with IBS who also have anxiety and/or depression.

Treating IBS

The good news for people with IBS is that various treatment plans have helped those living with the condition.

“Treatment of IBS involves long-term strategies using a combination of lifestyle changes, dietary modifications and medication to minimize symptoms,” said Dr. Sable.

Lifestyle and Dietary Changes

Keeping a dietary log will help one recognize foods that may trigger IBS symptoms. Avoiding items such as carbonated beverages, caffeine, alcohol, raw fruit, and cruciferous vegetables, such as cabbage, broccoli and cauliflower has been shown to help alleviate bloating and gassiness in some individuals.

Limiting caffeine and alcohol intake, minimizing dairy products, and avoiding sugar substitutes and artificial sweeteners can significantly decrease the frequency and urgency of diarrhea. Avoiding beans, uncooked vegetables and lowering the fat content of your foods may alleviate gassiness and bloating. Daily fiber supplements and increased water intake help with constipation.

In addition to dietary changes, lifestyle modifications help reduce symptoms in IBS as well.

“Smoking cessation is critical for overall health as well as the health of your intestinal tract,” said Dr. Sable. “Regular physical exercise has been shown to reduce the frequency of symptoms and protect against symptom deterioration”.

Medications for IBS

Keeping in mind that the treatment of IBS is multi-faceted, medications play an important role. Traditionally anticholinergic medications such as Bentyl and Nulev have been used to help temporarily alleviate bloating and discomfort. Imodium can be helpful for those with frequent diarrhea and urgency. Fiber supplements seem to benefit those with constipation.

Antidepressants and anti-anxiety medication may also provide some benefit for more chronic symptoms. Within the last several years, probiotics and even antibiotics have been used with some success in IBS. This benefit may be due, in part, to bacterial imbalances in the intestine that may exist in patients who suffer from IBS.

Some of the recently approved medications for IBS have a more specific focus. Several years ago, Lotronex (Alosetron) was approved for women with IBS and diarrhea; this medication is designed to relax the intestine and slow the transit of stool thereby helping with diarrhea and bloating. Only a gastroenterologist should prescribe this medication. Amitiza (Lubiprostone) is prescribed for adult women and men who have IBS with constipation. It is taken twice a day and works by increasing the fluid secretion into your intestine thereby softening your stool and increasing bowel movements. This medication has a long track record and has been shown to be safe and effective in patients with IBS-C and those with chronic constipation as well. Linzess (Linaclotide) is a novel medication that gained FDA approval in late 2012 to treat patients with chronic constipation and those with IBS and constipation.

How can I manage the pain?

Antispasmodic drugs relax the muscles of the gut, relieving the spasm and distension that causes pain. Some such as Buscopan and Merbentyl may have associated side effects such as a dry mouth and blurred vision and difficulty passing water.

	Generic Name	Brand Name
	Hyoscine	Buscopan
	Dicyclomine	Merbentyl
	Alverine Citrate	Spasmanol, Alvercol
	Peppermint Oil	Colpermin, Mintec
	Mebeverine Hydrochloride	Colofac

Although hyoscine and dicyclomine are strong antispasmodics, some patients may experience side effects with them. These include dry mouth, blurring of vision and urinary retention.

Antispasmodic medication can be purchased over the counter at your local pharmacist.

Antidepressants

“Low dose antidepressants can relieve IBS pain when analgesics fail.”

Pain that is resistant to antispasmodics may respond to treatment with low doses of antidepressants. This may be partly due to the alleviation of an underlying depression and partly because of a direct effect on pain pathways in the gut. Anxiety and depression can make people more sensitive to pain and can upset the bowels.

There are two classes of drugs.

	Genric Name	Brand Name
Amitryptyline	Tryptizol
Nortryptyline	Doxepin
Dothiepin Hydrochloride	Prothiadin

* Tricylic antidepressants tend to make constipation slightly worse.

	Generic Name	Brand Name
	Fluoxetine	Prozac
	Sertraline	Lustral
	Paroxetine	Seroxat
	Citalopram	Cipramil

*SSRIs can make the bowels more loose and may be more useful in people with constipation.
Antidepressants can only be obtained on prescription.

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Antispasmodic Medicines

Antispasmodic medicines are used to treat symptoms such as tummy pain and cramp (spasm). They are most often used for symptoms of irritable bowel syndrome. The side-effects that may occur are usually minor.

Antispasmodic Medicines

In this article

• What are antispasmodics?
• How do antispasmodics work?
• Which conditions are they used to treat?
• Which is the best one?
• How do I take antispasmodics?
• How quickly do antispasmodics work?
• How long is treatment needed for?
• Other considerations
• Who cannot take antispasmodics?
• Can I buy antispasmodic medicines?
• What are the possible side-effects?

What are antispasmodics?

Antispasmodics are a group (class) of medicines that can help to control some symptoms that arise from the gut (intestines) — in particular, gut spasm.

There are two main types, as follows.

Antimuscarinics such as:

Smooth muscle relaxants such as:

How do antispasmodics work?

The movement of food along your gut (intestines) happens because some of the muscles in the gut tense (contract) and then relax in a regular pattern throughout the length of the gut. These muscle contractions are brought about by various chemicals produced by your body which stick to special ‘docking’ sites (receptors) on the muscles.

However, in conditions such as irritable bowel syndrome (IBS) these muscle contractions can occur too often or be painful, causing symptoms such as pain and bloating.

Antimuscarinics work by attaching to the receptors and in this way stopping the chemicals from ‘docking’ there to make the muscle contract. Reducing the muscle contractions in this way often helps to relieve some of the symptoms caused by IBS.

Because muscarinic receptors are also found in other parts of the body, taking an antimuscarinic can have other effects. For example, muscarinic receptors also help to control the production of saliva in the mouth. Taking a medicine that blocks these receptors may cause a dry mouth.

Smooth muscle relaxants work directly on the smooth muscle in the wall of the gut. Here they help to relax the muscle and relieve the pain associated with a contraction of the gut.

Which conditions are they used to treat?

Antispasmodics are commonly used in IBS:

• To help relieve some of the symptoms of IBS such as spasm (colic), bloating and tummy (abdominal) pain.
• To reduce the movement (motility) of the gut (intestines).

Note: not everybody with IBS finds that antispasmodics work well. However, they are worth trying, as they work well in a good number of cases.

Antispasmodics are also used in some other conditions such as diverticular disease.

Which is the best one?

Overall, medical studies do not suggest one antispasmodic as more effective at relieving symptoms than another. However, some people seem to respond better to one type rather than another. Therefore, if one does not work so well, it is worth trying a different one.

The smooth muscle relaxants tend to have fewer side-effects, so they are usually tried first.

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How do I take antispasmodics?

Your doctor will advise you how to take your medication, including how often. You may be encouraged to use the medicine at a particular time in relation to eating. Some people take a dose before meals if pains tend to develop after eating.

It is generally recommended that you take these medicines only when necessary. For example, people with IBS commonly find that there are times when symptoms flare up for a while. So, it is common to take an antispasmodic when symptoms flare up, and to stop them if symptoms settle down.

Note: pains may ease with medication but may not go away completely.

How quickly do antispasmodics work?

Antispasmodics usually work within an hour or so to ease symptoms. Their effectiveness may depend on the dose you are given and how often you take them.

How long is treatment needed for?

These medicines are usually only used when you have active symptoms. However, this can vary depending on the reason for treating you. Your doctor should be able to advise you on this.

Other considerations

If you have IBS you may become used to having gut (intestinal) symptoms. However, do not assume all gut symptoms are due to your IBS. You should consult your doctor if you experience any change in the usual pattern of your symptoms. In particular, the following problems can indicate a serious gut disorder:

• Unintentional weight loss.
• Bleeding from the back passage (rectum).
• Blood in your stools (faeces) — this may colour your stools black.

Who cannot take antispasmodics?

Most people can take antispasmodics. There are a few exceptions. A full list of people who should not take antispasmodics is included with the information leaflet that comes with the medicine packet.

If you are prescribed antispasmodics, read this to be sure you are safe to take them. In particular, antispasmodics may not be suitable for people with:

• Paralytic ileus — a condition where the gut (intestinal) muscles are paralysed.
• A blocked gut (intestinal obstruction).
• Myasthenia gravis — a condition causing muscle weakness.
• Pyloric stenosis — narrowing of the outlet from the stomach.
• Prostate gland enlargement.

Pregnant or breastfeeding mothers should also seek advice before using these medicines. Avoiding these medicines if possible is usually recommended if you are pregnant or breastfeeding.

Can I buy antispasmodic medicines?

You can buy some antispasmodics from your pharmacist. Others are only available with a prescription.

What are the possible side-effects?

Most people who take antispasmodics do not have any serious side-effects. If side-effects occur, they are usually minor. In general, the smooth muscle-relaxant types tend to have fewer side-effects. The side-effects depend on which of the antispasmodic medicines you are taking. Some of the more common side-effects are:

• Heartburn
• Constipation
• Dry mouth
• Difficulty passing urine

Note: the above is not the full list of side-effects for these medicines. Please see the leaflet that comes with your particular brand for a full list of possible side-effects and cautions.

These medicines sometimes react with other medicines that you may take. So, make sure your doctor knows of any other medicines that you are taking, including ones that you have bought rather than been prescribed.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

• The side-effect.
• The name of the medicine which you think caused it.
• The person who had the side-effect.
• Your contact details as the reporter of the side-effect.

It is helpful if you have your medication — and/or the leaflet that came with it — with you while you fill out the report.