Treatment of Mixed Irritable Bowel Syndrome (IBS)

First-Line Treatments

The American Gastroenterological Association recommends simple dietary advice, including identification and reduction of excessive intake of lactose, fructose, sorbitol, caffeine, or alcohol, for patients with mixed IBS 3, 1
A trial of soluble fiber (ispaghula/psyllium) is recommended, starting with low doses (3-4g/day) and gradually increasing to avoid bloating, as suggested by the American College of Gastroenterology 1, 2
Patients with low fiber intake and constipation symptoms should be given a trial of high fiber diet, according to the National Institute of Diabetes and Digestive and Kidney Diseases 3
A low FODMAP diet under supervision of a trained dietitian may be considered for patients with persistent symptoms, as recommended by the American College of Gastroenterology 1
Regular exercise should be recommended to all mixed IBS patients as it provides significant benefits for symptom management, according to the American Heart Association 1, 2

Loperamide at doses of 4-12 mg daily effectively slows intestinal transit and reduces stool frequency and urgency, as reported by the American Gastroenterological Association 4, 1
Cholestyramine may be considered for patients who may have bile acid malabsorption, particularly those with post-cholecystectomy diarrhea, according to the National Institute of Diabetes and Digestive and Kidney Diseases 4, 1
Increased dietary fiber (25 g/day) is recommended for constipation symptoms, as suggested by the American College of Gastroenterology 4
Osmotic laxatives may be needed for more severe constipation, according to the American Gastroenterological Association 2

Tricyclic antidepressants (TCAs) are effective for pain and global symptoms in IBS with mixed patterns, as reported by the American Psychiatric Association 4, 1
Selective serotonin reuptake inhibitors (SSRIs) may be considered if TCAs are not tolerated, according to the American College of Gastroenterology 4, 1
Probiotics may improve global symptoms and abdominal pain; recommend a 12-week trial and discontinue if no improvement, as suggested by the World Gastroenterology Organisation 1, 2

Consider IBS-specific cognitive behavioral therapy or gut-directed hypnotherapy for patients with symptoms refractory to pharmacological treatment for 12 months, as recommended by the American Psychological Association 1, 2
Simple relaxation therapy may be beneficial as an initial psychological approach, according to the National Institute of Mental Health 3, 1

Establish a positive diagnosis, explain symptoms, their cause, and their relationship to physical, dietary, or psychological factors, as suggested by the American Gastroenterological Association 3
Recognize that IBS is a disorder of gut-brain interaction requiring explanation of the gut-brain axis to patients, according to the American College of Gastroenterology 1, 2
Avoid extensive testing once IBS diagnosis is established, as recommended by the American Gastroenterological Association 1, 2
Do not recommend diets of elimination based on antibodies IgG or gluten-free diets unless there is evidence of celiac disease, according to the American College of Gastroenterology 2
Acknowledge that symptoms may relapse and remit over time, requiring periodic adjustment of treatment strategy, as suggested by the American Gastroenterological Association 1
Recognize the frequent comorbidity with anxiety and depression that may require specific treatment, according to the American Psychiatric Association 2