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Pharmacologic Management of Irritable Bowel Syndrome.

of the Clinical Problem Irritable bowel syndrome is the most commonly diagnosed gastroenterologic condition, accounting for a substantial number of physician visits in both gastroenterology and primary care practices. The prevalence in North America is estimated to be 11.8%.1 Patients with IBS most commonly have irregular bowel habits in conjunction with abdominal pain or discomfort. The Rome III diagnostic criteria for IBS require the presence of recurrent abdominal pain or discomfort for at least 3 days per month during the last 3 months with onset of more than 6 months prior.2 These symptoms must also be associated with 2 or more of the following: improvement with defecation, change in stool frequency, or change in stool appearance or form. Irritable bowel syndrome is typically considered a diagnosis of exclusion, requiring initial evaluation for organic or structural causes, especially in the setting of symptom onset after age 50 years, unexplained iron deficiency anemia, rectal bleeding, weight loss, or nocturnal abdominal pain.3 All patients with suspected IBS should undergo colorectal cancer screening as dictated by their age and risk factors and a complete blood cell count. In patients with diarrhea, testing for celiac disease as well as colonoscopy with random biopsies should be considered. Obtaining serum or stool inflammatory marker measurements such as C-reactive protein or fecal calprotectin may also be part of the initial evaluation as well.4 The Rome III criteria stratify IBS into subtypes based on the predominant feature of the bowel symptoms: IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), mixed-type IBS (IBS-M), and unclassified IBS (IBS-U). The subtype of IBS often dictates which pharmacologic agents should be considered in the treatment, although there are limited therapies specific to IBS-M and IBS-U. Characteristics of the Guideline Source This guideline was developed by the Clinical Practice and Quality Measures Committee (currently the Clinical Practice Guideline Committee) and approved by the AGA Governing Board (Table).5 The development of the guideline was based on results of a technical review published by the AGA that provided a systematic evaluation of current pharmacologic treatments in the management of IBS.6 The members of the guideline panel included 10 gastroenterology experts who met with AGA support staff, a patient/consumer representative, and authors of the technical review. The strength of each recommendation was determined to be either strong or conditional in conjunction with a rating of the associated evidence as low, moderate, or high quality. A strong recommendation implies that most patients should receive the recommended course of action, while a conditional recommendation means that the treatment decision should be individualized for the patient.7 All members completed a disclosure statement regarding any financial, professional, or intellectual conflicts of interest;