Treatment of Irritable Bowel Syndrome
& NATURAL REMDIES
by William B. Salt II, M.D. and Neil
F. Neimark, M.D.
The Science of Medical Treatment for IBS
Jailwala, Imperiale and Kroenke have
written a review of scientific studies published up to the year 2000 on
drug treatment of IBS (Annals of
Internal Medicine, 2000;133:136–147). These researchers concluded
Antispasmodics/smooth muscle relaxant
drugs are beneficial when pain is the predominant symptom.
Loperamide (brand name Imodium;
generic drugs available) is effective for diarrhea but not for pain.
Bulking agents improve constipation
and stool consistency but do not improve pain.
Chinese herbal medications and other
medications that have been studied sporadically and in small trials need
to be further investigated before specific conclusions can be drawn.
Some antidepressant drugs appear to be
effective in the treatment of some of the symptoms of functional gut
Additional studies support the value
of antispasmodic drugs for the treatment of abdominal pain (Alimentary
Pharmacology & Therapeutics, 1994;8:499–510 and
Medical treatment for patients with
IBS is usually directed to the predominant symptoms, which include
abdominal discomfort and pain, diarrhea, constipation and
bloating/distention (Drossman D.A., Whitehead W.E., Camilleri M., et al.
“Irritable Bowel Syndrome: A Technical Review for Guidelines
Abdominal discomfort and pain
When the main symptom of IBS is
abdominal pain, drug choices include antispasmodics, analgesic drugs
(non-narcotic and narcotic), antidepressant drugs (see later discussion)
and newer 5-HT drugs (see later discussion).
are three classes of antispasmodics, or drugs that decrease gut
contraction and spasm.
work by blocking the effects of the parasympathetic branch of the
autonomic nervous system. Examples include dicyclomine (Bentyl is a brand
name), hyoscyamine (brand names Anaspaz, Levsin, Levsinex and NuLev),
glycopyr-rolate (brand name Robinul), methscopolamine bromide (brand name
Pamine) and propantheline (a brand name is Probanthine). One drug (a brand
name is Librax) is an anticholinergic drug called clidinium combined with
a benzodiazepine antianxiety drug called chlordiazepoxide. Another (brand
names Donnatal and Donnatal Extentabs) combines two anticholinergic drugs
called atropine and scopolamine with a barbiturate antianxiety drug called
smooth muscle relaxants act directly upon the smooth muscle of the
gut. Studies show that the direct smooth muscle relaxants may be the most
effective of the antispasmodics, but these drugs are not available in the
United States. Examples of direct smooth muscle relaxant drugs include
octylonium, mebeverine and trimebutine.
oil is thought to work by decreasing calcium entry into muscle cells,
resulting in muscle relaxation. Enteric-coated preparations may be
preferable to unprotected peppermint because they allow delivery of the
peppermint oil to the colon. Peppermint oil may or may not be effective.
Scientific studies of the oil’s use are inconclusive.
drugs. Analgesic drugs are either non-narcotic or
analgesic drugs (aspirin, acetaminophen, nonsteroidal anti-inflammatory
drugs, also known as NSAIDS) are usually of little benefit in treating the
abdominal pain of IBS. Tramadol (brand name Ultram), is a non-narcotic
analgesic drug that binds to opiate receptors in the brain and alters
serotonin and norepinephrine re-uptake, which inhibits the transmission of
pain signals to the brain through ascending pathways from the body and
gut. It is best to begin with a very low dosage and gradually increase it
over several days to reduce the likelihood of unacceptable side effects
analgesic drugs are usually not prescribed for continuous treatment
because of possible development of physical dependency or addiction and
unwanted side effects, such as drowsiness and interference with clear
thinking. Furthermore, continuous narcotic use can actually increase pain
sensitivity and also alter gut motility, leading to severe constipation.
This is called the “narcotic bowel syndrome” (Annals
of Internal Medicine, 1984;101:331–334). Keeping these cautions in
mind, narcotic analgesic drugs are occasionally used to relieve
intermittent attacks of more severe pain.
There are two main functional
gastrointestinal disorders where diarrhea is a prominent symptom: (1)
chronic functional diarrhea and (2) the more common diarrhea-predominant
IBS, or D-IBS.
Treatment choices include the opioid
agonists loperamide (a brand name Imodium; generic available) and
diphenoxylate (a brand name Lomotil; generic available). Diphenoxylate
also contains atropine, which is an antispasmodic discussed earlier.
Two drugs that are used to lower
blood cholesterol can be helpful for some patients with chronic diarrhea,
especially if the problem tends to occur in the morning, is triggered by
meals or develops after surgical removal of the gallbladder. These drugs
are cholestyramine (brand name Questran; generic available) and colestipol
(brand name Colestid; generic available).
Narcotic drugs, such as codeine, are
opioid agonists and have consti-pation as a potential side effect, so they
may relieve diarrhea. However, because they cross into the brain, they can
have unwanted side effects of sedation and drowsiness, and they can lead
to physical dependency and addiction (see earlier discussion of narcotic
Unless a dietary factor can be
identified as a trigger or cause of chronic diarrhea, opioid agonists are
usually recommended first. Studies show that loperamide reduces the
urgency and frequency of bowel movements in patients with
diarrhea-predominant IBS. Furthermore, loperamide can increase stool
consistency and strengthen anal sphincter tone, which can be helpful if
fecal incontinence is a problem. Loperamide does not get into the brain
through the blood-brain barrier and is usually preferred over other
opioids, such as codeine or diphenoxylate. However, none of these agents
have been shown to relieve the pain associated with IBS. The drugs can
either be taken regularly or on a prophylactic basis. If a “morning
rush” occurs, then the drug could be taken at bedtime.
A study has shown that tricyclic
antidepressant drugs (TCAs) may relieve diarrhea and associated pain in
some patients with IBS, in part by their anticholinergic effects. Refer to
the preceding discussion on “Anticholinergics” and to the later
discussion on “Antidepressant Drugs.”
There are two functional gut
disorders where constipation is a prominent symptom: (1)
constipation-predominant IBS, or C-IBS and (2) functional constipation.
Remember that the normal frequency of bowel movements ranges from three
per day to three per week.
When constipation is the predominant
symptom, the first step for most patients is a trial of adequate dietary
fiber intake. Additional options include laxatives and medications.
fiber and fiber supplements (bulk agents or bulk laxatives). Most
people, including doctors, do not appreciate the potential benefits of
adequate fiber intake and how to incorporate fiber into the diet. Most who
have mild to moderate uncomplicated constipation improve when fiber intake
is increased. Those who either fail to respond to increased fiber intake,
cannot tolerate it or require additional help may need to utilize
are two types of laxatives, osmotic and stimulant. Osmotic laxatives are
not absorbed and most require a prescription. They soften the stool and
have an onset of action of one to three days. One type of osmotic laxative
is polyethylene glycol, or PEG (a brand name is Miralax). Another is
unabsorbed carbohydrate (lactulose and sorbitol). Glycerine suppositories
are available without prescription.
Stimulant laxatives interfere with
absorption and motility and are available without prescription. They have
an onset of action of six to twelve hours and produce a soft to semi-fluid
stool. They include saline laxatives (brand names Milk of Magnesia and
Citrate of Magnesia); diphenylmethane derivatives (brand name Dulcolax);
and anthraquinone derivatives (senna, cascara sagrada and aloin).
Anthraquinones are widely available.
They may also be included in many “natural” remedies (see later
discussion) that are advertised as colon health products, herbal laxatives
and even teas. These laxatives may or may not be identified in the list of
ingredients. If they are identified, they may be described as harmless and
“natural,” such as locust plant or Cassia
angustofolia (senna). Make sure to tell your doctor if you are taking
one of these products.
use of laxatives. The belief that stimulant laxatives can
damage the colon is probably untrue. This is the conclusion drawn by Dr.
Arnold Wald, a gastroenterologist at the University of Pittsburgh Medical
Center, who is an expert on constipation. We agree with his
recommendations that chronic use of laxatives is not harmful when they are
used appropriately. Remember that most people with constipation can be
adequately relieved with adequate dietary fiber intake. Osmotic laxatives
can be used on a daily basis. If necessary for symptom relief, stimulant
laxatives should be used no more often than two to three times weekly (4th
International Symposium on Functional Gastrointestinal Disorders,
March 30–April 2, 2001, Milwaukee, WI).
Bloating and distention
No drug therapies have been
confirmed to benefit bloating and distention; however, antidepressant
drugs may help (see next section on Antidepressant Drugs). A recent study
suggested that patients who took one capsule of pancreatic enzyme
supplement prior to eating high-fat meals (brand name Creon 10; available
by prescription) significantly minimized their abdominal bloating,
flatulence and nausea (Digestive Diseases and Sciences, July, 1999).
Antidepressants are commonly
prescribed for IBS and other functional gut and bodily symptoms and
syndromes, even though the Food and Drug Administration (FDA) does not
specifically approve them for this purpose unless depression is present.
This is called an “off-label” indication. Nevertheless,
antidepressants can be helpful in bringing symptom relief in IBS and other
functional syndromes, such as fibromyalgia (American
Journal of Medicine, 2000 Jan;108(1):65–72; Journal of General Internal Medicine, 2000 Sep;15(9):659–66). If
depression is present, then a full antidepressant drug dose is necessary.
If depression is not present, then lower doses may be effective.
At Digestive Disease Week 2001 in
Atlanta, Georgia, University of North Carolina gastroenterologist Douglas
A. Drossman said that, “The use of antidepressants in IBS and other GI
disorders is growing.” When symptoms become repetitive, severe and/or
are associated with alteration in quality of life, antidepressant drugs
can be considered.
Antidepressants have effects on gut
motility (contractions) and sensation and also may have pain modulatory
benefits. Antidepressant drugs are not addictive. The following list gives
examples of antidepressants in each of three classes. Brand names are
given in parentheses
Serotonin Re-uptake Inhibitors (SSRIs)
Questions for you and your doctor
Antidepressant drugs may be of
benefit in the treatment of abdominal pain and discomfort associated with
IBS; however, the tricyclic anti-depressants (TCAs) have proven to be more
effective than the selective serotonin re-uptake inhibitors (SSRIs) in the
small number of scientific studies that have been conducted. The efficacy
of SSRIs in treatment of functional gut syndromes such as IBS is currently
being investigated. In clinical practice, finding the best drug is often a
matter addressing several important questions:
you depressed, along with your digestive symptoms? If so, then an
antidepressant drug dose will be needed, because the presence of
depression can magnify and amplify your symptoms. If you are not
depressed, then lower antidepressant drug doses may be effective.
you have previous experience with antidepressant drugs? If a drug
helped before, it may be wise to select the same one again. But, if a
specific antidepressant was not helpful before or caused unacceptable side
effects, then it doesn’t make much sense to try it again.
you have concerns about taking antidepressants? If you have taken
antidepressant drugs previously, inform your doctor about which drug or
drugs that you have taken, whether they helped or whether they caused
unacceptable side effects. Also, discuss any reluctance that you may have
regarding taking antidepressants. The purpose of treatment with an
antidepressant drug is to help you to feel better and not to alter your
mind adversely. Antidepressant drugs are not addictive.
you also have other functional symptoms and/or syndromes, such as
fibromyalgia and interstitial cystitis? If so, then
antidepressant drugs may be helpful in reducing or relieving more than
just the digestive symptoms.
you have a family member or family members who have benefited from a
specific antidepressant or had unwanted side effects? Remember
what you have learned about your family history. You may want to take this
into consideration when you and your doctor select an antidepressant.
you have any significant health problems, especially with your heart and
circulation, liver and kidneys? For example, it may be important
to avoid the TCAs if you have heart arrhythmia.
are your predominant symptoms?
or discomfort: TCAs may be the best initial choice.
antidepressants have constipation as a side effect and could be helpful
antidepressants are more likely to cause diarrhea, which might improve the
constipation. TCAs have not been shown to be beneficial in treatment of
constipation and may either cause or aggravate the condition.
problems: some antidepressants are more helpful in promoting
sleep than others, and some may actually interfere with sleep.
or sluggish: some antidepressants can boost energy.
or jittery: some drugs can bring a calming effect.
It can take several weeks for an
antidepressant to take effect. If treatment is stopped too soon, then it
may appear that the treatment did not work. If you experience side
effects, discuss them with your doctor. Most side effects will either
diminish or go away completely after several days, or they can be reduced
temporarily by lowering the dose. Furthermore, the decision to continue
treatment or consider a change of medication can be re-evaluated at a
later appointment. Since everyone is different, trying one or more
different antidepressant drugs may be necessary in order to find the one
that is best for you.
Unwanted side effects
Space will not permit a detailed
discussion of potential antidepressant drug side effects, but a common one
is sexual dysfunction. Unfortunately, some of the antidepressant drugs
interfere with sexuality and sexual function by reducing libido or causing
difficulty with achievement of erection or orgasm. The antidepressant
drugs that are less likely to cause this problem are buproprion (brand
name Wellbutrin), mirtazepine (brand name Remeron), Nefazedone (brand name
Serzone) and possibly citalopram (brand name Celexa).
Antianxiety Drugs (Anxiolytics)
Anxiety may be associated with IBS.
If so, then antianxiety drugs, called anxiolytics, may be helpful.
are commonly used in the treatment of anxiety, but they can cause
drowsiness, sedation, memory impairment and interactions with other drugs
and alcohol. Furthermore, physical dependency can develop, so that
physical withdrawal symptoms and rebound anxiety can occur upon
discontinuation. It is for this reason that discontinuation of long-term
benzodiazepine treatment requires a slow tapering of dose. Finally,
benzodiazepines may cause or aggravate depression. For these reasons, they
are usually prescribed only when anxiety is moderate to severe. The most
commonly prescribed benzodiazepines (brand names in parentheses) are
clonazepam (Klonopin); diazepam (Valium); lorazepam (Ativan); and
alprazolam (Xanax). Generic versions of each are available.
(brand name is BuSpar)
Buspirone is a non-benzodiazepine
drug that is approved for treatment of chronic anxiety. It is less likely
to cause drowsiness and sedation than benzodiazepines, but dizziness and
nausea can occur during initial treatment.
Antidepressant drugs can be used in
the treatment of anxiety.
Newer drugs have been developed that
are agonists (drugs that enhance) and antagonists (drugs that block) the
effects of the neurotransmitter 5-HT (serotonin) in the gut.
Alosetron (brand name Lotronex) is a
5-HT3 antagonist used to treat diarrhea-predominant IBS in women (it has
not been shown to be effective in men during research). It was withdrawn
from the U.S. market in 2000 because of concerns over its safety. The most
common side effect was constipation, but a type of colon inflammation
called ischemic colitis was found to be associated with, although not
definitely caused by, the drug.
Tegaserod (brand name Zelnorm) is a
5-HT4 agonist designed to treat constipation-predominant IBS. It should be
a promising treatment for C-IBS, but it has not yet been approved for use
in the United States by the FDA. Scientific studies have shown that if
side effects do occur, they are minor (headache, diarrhea). No cases of
ischemic colitis have been reported.
The placebo response is evidence of
the remarkable self-healing capacity that we all have. Howard Brody, M.D.,
is a physician at Michigan State University who has written a book called The Placebo Response: How You Can Release the Body’s Inner Pharmacy
for Better Health. He defines the placebo response as “a change in
the body (or the body-mind unit) that occurs as the result of the symbolic
significance that one attributes to an event or object in the healing
environment.” As UCLA gastroenterologist Dr. Emeran Mayer has written,
“If we are honest with ourselves, treatment practices do not necessarily
have to be better than placebo to find a useful place in medical practice,
and honest practitioners have used this approach to the benefit of their
patients for many years. Conversely, practitioners who eschew the healing
arts in favor of only offering their patients scientific evidence-based
therapies may be justifiably accused of doing their patients a serious
disservice” (The Neuro-biology Basis of Mind Body Medicine, The International
Foundation for Functional Gastrointestinal Disorders, 2001).
Most of the evidence for efficacy of
“natural” remedies and herbal products is empirically derived, which
means that recommendations and usage are based upon repeated experience
and observation throughout history. Few have been subjected to the rigors
of scientific testing. But even if no better than placebo, “natural”
remedies may be helpful. Numerous products are now available, marketed as
daily dietary supplements, in accordance with the Dietary Supplement
Health and Education Act (DSHEA). DSHEA products carry nutrition support
statements that may include claims regarding the effects of the product on
the structure or function of the body. In doing so, they must carry the
following disclaimer: “This
statement has not been evaluated by the Food and Drug Administration. This
product is not intended to diagnose, treat, cure or prevent any disease.”
General Recommendations about “Natural” Medicines
If you decide to take natural
remedies or herbal medicines, here are our recommendations.
Don’t take them if you don’t need
You may need to experiment with herbal
remedies, since most of the evidence for efficacy is empirical, meaning
that recommendations and usage are based upon repeated experience and
observation throughout history. Few have been subjected to the rigors of
scientific testing. Allow your experience to be your guide and use only
those remedies that provide you with consistent benefits.
Be sure to let your doctor know about
it, particularly since some of these treatments can react with
Herbal products may be contaminated or
adulterated, and they may not contain advertised amounts of the active
ingredients. So, purchase reputable brands that also advertise the purity
of their ingredients. Search for herbal preparations that have been
“wildcrafted” (harvested from wild stands) or cultivated organically.
Discontinue use if you have an adverse
Tinctures (alcohol based) and
freeze-dried extracts of herbals are usually the best preparations to
Loose herbs that are sold in bulk and
powdered herbals within capsules are less likely to be effective.
Here is a brief description of some
of the most commonly used “natural” remedies and herbal products.
is a probiotic (see later discussion) that consists of dried or liquid
cultures of live bacteria that sour milk and are considered beneficial or
“friendly” to the GI tract. Health food stores carry acidophilus in
preparations that have much higher concentrations of the bacteria than are
found in yogurt and acidophilus milk.
for: IBS, diarrhea or to avoid diarrhea when taking antibiotics
or aloe vera. The clear gel from the aloe plant is used
in many skin lotions, creams and cosmetics because of its moisturizing
properties. Aloe vera juice, sold in health food stores, can be taken
internally. If the dose is too high, it can have a laxative effect. A
reasonable amount to try is 1 teaspoon after meals. The fresh gel can be
mashed up in fruit juice. There is variation in palatability, so it may be
necessary to try different brands.
for: Inflammatory bowel disease (Crohn’s disease and ulcerative
five senses send information to the limbic system. Aromatherapy is based
upon the fact that sense of smell is the only sense that is wired directly
into the limbic system. Scents that are purported to be helpful in IBS
include peppermint, eucalyptus, lavender and rose oil. A certified
aromatherapist ensures use of essential oils and not synthetic chemicals.
(brand name). Beano is manufactured by AKPharma, Inc.,
the manufacturers of Lactaid and Prelief. Beano contains an enzyme called
alpha-galactosidase that digests the indigestible carbohydrate (raffinose)
contained in beans and some vegetables. Beano has no effect on gas
associated with other carbohydrates, such as sorbitol, lactose, wheat and
fiber. It cannot be added to food while it is being cooked, since heat
degrades the enzyme.
glycerophosphate (brand name Prelief). The manufacturer
of Prelief, AKPharma, Inc., advertises that, “Prelief takes acid out of
food. Prelief reduces the acid in all food and beverages so you can enjoy
a more comfortable diet.”
for: Food sensitivity, IBS, interstitial cystitis
is the dried flowers of the perennial chamomile plant. It is available as
an extract, oil and tea.
for: Nausea, dyspepsia, IBS, anxiety
charcoal tablets or capsules (brand names include Charco Caps and Charcoal
Plus) may help provide relief from flatulence by reducing intestinal gas.
herbal medicine. Chinese herbal medicine has been used
in China for centuries in the treatment of IBS symptoms. A recent
scientific study published in the Journal of the American Medical Association (1998;280:1585–1590)
concluded that Chinese herbal medicine may be beneficial in the treatment
of IBS. The product used was supplied by Mei Yu Imports.
copper. Products that contain chlorophyllin copper
(brand names include Nullo and Derifil) may help to reduce the offending
odor of flatus.
for: Malodorous flatulence
(Foeniculum vulgare) includes the seeds, leaves and roots of the fennel
plant. It is available in plain seeds, sugar coated seeds, extract, oil
and capsules. The adult dose is one half-teaspoon of fennel seeds chewed
after eating or whenever symptoms are bothersome, or as recommended on the
for: Rectal gas and flatulence
for: Source of fiber and omega-3 fatty acids
is a spice that is available in fresh form from supermarkets, as candied
ginger, honey-based ginger syrups, tinctures and powdered extract in
for: Nausea, dyspepsia
is a derivative of a plant indigenous to the South Sea Islands (Piper
methysticum) that has a mild relaxant and antianxiety effect.
enzyme. Brand names of products containing lactase
enzyme for lactose intolerance include Lactaid, Dairy-Ease and Lactrase.
for: Lactose intolerance
flower. Passion flower is an herbal made from a Native
American plant (Passiflora incarnata) that has a mild relaxant effect.
is available in capsules that have a protective coating that resists
digestion by the stomach acid so that the peppermint can be released in
the colon. There are several brands available, but we recommend the brand
names of Mintacin or Peppermint Plus (manufactured by Enzymatic Therapy,
is the term used to describe health-promoting “friendly” bacteria
ingested orally. These bacteria in the intestine purportedly provide a
protective effect only when a proper balance is maintained among all the
different bacteria that normally reside in the intestine. If normal
bacteria become depleted or the balance is disturbed by diet, infection,
antibiotic use, lifestyle changes or stress, then potentially harmful
“unfriendly” bacteria can overgrow and become established, leading to
digestive and other health problems. These harmful bacteria are alleged to
have the ability to cause gastrointestinal problems such as diarrhea,
abdominal pain and/or bloating if not kept in check by the beneficial
bacteria. Furthermore, probiotics supposedly promote digestive health,
balance and function and help maintain a healthy balance of “good”
bacteria in the digestive tract.
Probiotics are credited with an
impressive list of therapeutic and prophylactic attributes. The probiotics
industry is flourishing, and interest in establishing scientific
credibility has attained importance for many companies and scientists.
Probiotics are the subject of considerable scientific research. For now,
if you decide to try a probiotic, the most commonly recognized probiotics
are the lactic acid bacteria that include lactobacilli, streptococci
and/or bifidobacterium. Some commercially available products include Lactobacillus
acidophilus (many brands available); Lactobacillus
reuteri (brand name Probiotica), manufactured by McNeil, the company
that makes Imodium; Lactobacillus GG
(brand name Culturelle), made by CAG Functional Foods—a ConAgra Company;
and Saccharomyces boulardii.
for: A variety of gut symptoms and digestive health
(s-Adenosyl methionine). This dietary supplement is a
prescription drug for depression in Europe, but it is available in the
United States without prescription and promoted as a natural product for
the treatment of depression or arthritis. SAMe contains an important
compound that is produced by all living cells, which is involved in the
regulation of several hormones and neurotransmitter chemical messengers,
such as serotonin and epinephrine. SAMe is expensive.
for: Depression (not severe or associated with suicidal ideation)
is a foaming agent that joins gas bubbles in the stomach, which may
increase the amount of gas that can be belched away. Brand names include
Gas-X, Mylanta Gas and Phazyme. Simethi-cone has no effect on intestinal
elm. Slippery elm is obtained from the inner bark of
the red elm tree and is said to restore the normal mucus coating on
irritated tissues. Slippery elm lozenges can be found in most grocery
for: Inflammatory bowel disease (Crohn’s disease and ulcerative
John’s wort. St. John’s wort (Hypericum perforatum)
may be useful in treating depression, although scientific studies are
for: Depression (not severe or associated with suicidal ideation)
is an Ayurvedic Indian mixture used to treat constipation and poor bowel
tone. Indian practitioners of Ayur-vedic medicine recommend two Indian
brands: Dabur and Hammdar. The dose is two capsules per day or as
recommended by the manufacturer.
for: Constipation and poor bowel tone
from the root of an European plant, Valeriana officinalis was the main
sedative and hypnotic in use in Europe and America before the invention of
barbiturates in the early twentieth century.
for: Sleep aid
Irritable Bowel Syndrome and the
MindBodySpirit Connection by William B. Salt II, M.D. and Neil F.
Neimark, M.D.. Copyright ©
2002 by William B. Salt II, M.D. Excerpted by arrangement with Parkview
Publishing. $19.95. Available in local bookstores or call 888-599-6464 or click