Table 8 Summary of recommendations for pharmacological treatment of irritable bowel syndrome
InterventionQuality ofBenefit/Strength ofComments
evidenceharmrecommendation
Antispasmodics
MebeverineLowNet benefitQualified
Alverine citrateVery lowUncertain trade-offsDefinitive
DicyclomineVery lowUncertain trade-offsDefinitive
Fibre supplements
IspaghulaHighNet benefitDefinitive
BranHighNo net benefitDefinitiveHalf are made worse
Opioids
LoperamideHighNet benefitDefinitiveHelps diarrhoea but less effect on pain/discomfort
Tricyclic antidepressants
DesimipramineModerateTrade-offsQualifiedIneffective on intention to treat analysis
Poorly tolerated at full dose
AmitriptylineLowTrade-offsQualifiedPoorly tolerated at full dose
Nortriptyline
SSRIsBetter tolerated than TCAs
ParoxetineHighNet benefitQualifiedGlobal benefit without benefit to specific bowel symptoms
FluoxetineHighNet benefitQualifiedGlobal benefit
5-HT4 agonistsProkinetic; benefit IBS-C
TegaserodHighNet benefitDefinitiveNNT = 14
5-HT3 antagonistsAntidiarrhoeal; benefit IBS-D
AlosetronHighTrade-offsDefinitiveNNT = 7
“Ischaemic” colitis, 1/700
ProbioticsModerateTrade-offsQualified
AntibioticsLowTrade-offsQualifiedControversial; needs replicating
  • IBS-C, constipation predominant irritable bowel syndrome; IBS-D, diarrhoea predominant irritable bowel syndrome; NNT, number needed to treat; TCA, tricyclic antidepressant.