Irritable bowel syndrome

Gastrointestinal Conditions

Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.

Clinical features

Abdominal pain or discomfort (especially in the left lower quadrant of the abdomen) that is relieved by defaecation or associated with altered bowel frequency (increased or decreased) or stool formation (hard, lumpy, lose or watery)

Bloating, altered stool passage and passage of mucus may occur; symptoms may be made worse by eating. The NHS mentions that IBS may also be associated with lethargy, nausea, back pain, headache, bladder symptoms, dyspareunia, or faecal incontinence

First time sufferers (OTC product licence restriction) and consider referring children as IBS is not common in this patient group (and there will typically be an age limit on OTC IBS products)

This is a chronic multifactorial condition with fluctuating symptoms; patients will typically experience flare-ups related to aggravating factors, such as stress

Non-pharmacological advice

IBS is a chronic condition which can be triggered by stress, various medicines and foods. Triggers such as sources of stress should be identified and minimised (through relaxation time and techniques, and undertaking regular exercise is also important)
You can reassure the person that IBS is not associated with an increased risk of cancer or mortality (although remember that some cancers may have a similar presentation to IBS such as colorectal cancer, small bowel cancer and ovarian cancer)

There are various resources that people can be signposted to, including NHS leaflets and the IBS Network

Dietary advice. Have regular meals and don't rush these. The person should be encouraged to lose weight if required. The amount of fibre may need to be adjusted (i.e. reduce intake of insoluble fibre and increase soluble fibre). Additionally, to minimize flatulence and bloating, increase fibre gradually and be mindful of consuming flatulence-producing foods and drinks (and limit caffeine, alcohol and sugary/fizzy drinks)

It is good practice to give all patients with IBS advice on diet, lifestyle, and mental wellbeing

Pharmacological advice

Cochrane Systematic Review by Ruepert (2011) concluded that antispasmodics as a class of medicines when compared to placebo, provided a statistically significant benefit for abdominal pain, global assessment and IBS symptom score. However, the only OTC product with which the review found evidence of efficacy was peppermint oil (in terms of global assessment and IBS symptom score). Direct-acting smooth muscle relaxants (mebeverine hydrochloride, alverine citrate, and peppermint oil) are normally recommended for ongoing symptoms of abdominal pain or spasm

Probiotics may be effective in IBS, however the size of the effect and the effectiveness of individual probiotics is still to be established

For people with constipation, soluble fibre supplements (for example, ispaghula) or foods high in soluble fibre (for example, oats and linseed), should be introduced gradually to minimise side-effects such as flatulence and bloating

NICE IBS pathway and BNF state to consider treatment with a laxative (but discourage use of lactulose). For people who cannot tolerate a bulk-forming laxative such as ispaghula, or if an additional laxative is required, a macrogol or stimulant laxative (for short-term use only) should be recommended. Also check the OTC product is licenced for use in IBS

For people with diarrhoea, reduce intake of insoluble fibre and foods that could exacerbate symptoms like caffeine, alcohol, fizzy drinks or other substances known to produce gas and hence cause bloating and flatulence. Loperamide is useful in ongoing management and the BNF states (in the context of IBS-related diarrhoea) that loperamide is the first-line choice of antimotility drug. There are OTC loperamide-based products licensed for use in IBS, but check individual products first and take care about use in those with a history of drug abuse

Pregnancy: this is not a condition that is typically managed OTC and the manufacturer may not have enough safety data in relation to use of their OTC product for IBS during pregnancy