Anticholinergic drugs Anticholinergic medications block or slow nerve impulses at parasympathetic nerve endings. This prevents muscle contraction and gland secretion in the organs involved. These medications are thought to slow the action of the bowel and relieve spasms (antispasmodic) through relaxation of the muscles. Dicyclomine and hyoscyamine are sometimes considered antispasmodics, but typically relieve abdominal pain through anticholinergic activity (small and large bowel spasms are not typically associated with IBS). These anticholinergic properties sometimes increase gastrointestinal motility and secretion and reduce bowel movement frequency and liquidity. These medications are used infrequently due to the incidence of side effects including visual disturbances, urinary dysfunction, and constipation (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). Antidiarrheal drugs Antidiarrheals are typically used to control chronic diarrhea caused by IBS or IBD. In general, antidiarrheal drugs should only be used in cases of mild to moderate diarrhea and should not be used by individuals with blood in their stool, a high fever, or other condition that might cause systemic toxicity or worsen the pre-existing condition. They also should not be used in individuals with diarrhea that worsens after administration of any antidiarrheal drug (Lee, 2015). The main opioid used as an antidiarrheal agent is loperamide. Loperamide has constipating effects, leading to increased transit time and greater absorption of water by the fecal matter. At the same time, opioids inhibit the gastrocolic reflex, slowing colonic movements. Over longer periods of time or larger doses, opioids can have effects on the central nervous system and create the potential risk of addiction (Lee, 2015). Opioids and anticholinergics, like diphenoxylate and loperamide, are used together to slow the action of the bowel, relieving diarrhea. Loperamide is a nonprescription opioid that does not cross the blood-brain barrier and appears to have no analgesic properties or potential for addiction. Diphenoxylate also has no analgesic properties at normal doses but may have central nervous effects or potential for addiction with higher or prolonged usage. Some opioid preparations also have atropine, which has anticholinergic properties that assist in antidiarrheal action (Jain & Wylie, 2023). Altered parasympathetic action (abnormal relaxation response) may be a concern for manual therapy. Kaolin is hydrated magnesium aluminum silicate, a natural clay-like substance known as attapulgite . Pectin is indigestible carbohydrate made from apples. Both absorb bacteria, toxins, and fluid into the stool, increasing their production and liquidity. Useful in acute diarrhea, neither should be used for prolonged periods. Kaolin/pectin solutions are not absorbed and have a low incidence of side effects like constipation. Because they may bind to other medications, they should be carefully timed around the ingestion of other drugs (Papich, 2021). Antiemetic drugs Alosetron is a powerful 5-HT3 antagonist that works by inhibiting 5-HT3 receptors in the gastrointestinal tract, minimizing visceral afferent pain and intestinal motility. Alosetron is approved for individuals with severe IBS with diarrhea. Alosetron is highly specific to the 5-HT3 receptor that is rapidly absorbed from the gastrointestinal tract. Alosetron is subject to hepatic metabolism and is excreted in urine. Alosetron inhibits distention-induced sensory and motor reflex activation as well as central response to visceral
stimulation due to the fact that it blocks 5-HT3 receptors on enteric afferent neutrons inhibiting colonic motility, particularly in the left colon, and increasing the duration of transit time in the colon (Butt & Kasmin, 2022). While aldosterone is currently approved for the treatment of women experiencing IBS with diarrhea as the primary symptom, efficacy in use among men has not been supported by research data. Among women, about one- half of individuals taking aldosterone find relief from pain or discomfort and a reduction in bowel movements (Lacy et al., 2018). Because aldosterone is associated, in rare cases, with gastrointestinal toxicity, it should be discontinued if constipation occurs (about 30% of users). In very rare cases (1 out of 1,000 users), constipation has resulted in complications requiring hospitalization or surgery, and ischemic colitis in as many as 3 out of 1,000 users. Due to the seriousness of these side effects, aldosterone is only approved in women with diarrhea-prone IBS who have not responded to other strategies and are aware of the risks. Aldosterone appears to have no significant interactions with other drugs (Butt & Kasmin, 2022). Tegoserod is a partial serotonin 5-HT4 receptor agonist with a similar structure to serotonin. Tegaserod has a bioavailability of about 10 percent and should be taken before meals, as food can further reduce its bioavailability. About 2/3 of the drug is excreted virtually unchanged in fecal matter, while 1/3 is eliminated as a metabolite in the urine. Tegoserod should not be used by individuals with hepatic or renal dysfunction (Madia et al., 2020). Research suggests that stimulation of 5-HT4 receptors on mucosal afferent nerve fibers triggers the release of neurotransmitters, stimulating the peristaltic reflex (bowel contraction and bowel relaxation) and promoting gastric emptying, increasing movement through the small and large bowel. Stimulation of the 5-HT4 receptors also leads to increased liquidity of the stool (Zhao et al., 2021). Tegaserod was approved for the treatment of IBS associated with constipation. Tegaserod appears to reduce pain and bloating, increase the number of bowel movements, and decrease stool hardness compared to the placebo. Diarrhea occurs in less than 10% of users within the first few days of treatment but normalizes in most individuals. Headaches may be another side effect. There are no known drug interactions (Madia et al., 2020). Antiflatulent drugs Antiflatulent drugs facilitate the release of gas pockets in the abdominal tract. These drugs are all easily available at local pharmacies and without a prescription. Gentle abdominal massage can facilitate the process. Gentle abdominal massage can also relieve mild side effects of cramping and diarrhea from stimulant and lubricant laxatives. Any significant abdominal pain, distention, constipation, or diarrhea should be referred to a physician. Healthcare Consideration: A patient may feel hesitant about talking to you about their gas, and even more embarrassed to pass it during an abdominal massage session. Most often, a patient will say things like “I’m feeling bloated, so I don’t know if I will feel comfortable being on my stomach on the table.” There is an entry for you here to educate your patient about the benefits of abdominal massage for someone who is experiencing gas. Explain how massage with gently clockwise strokes following the large intestine, rocking, and mimicking peristalsis can encourage the movement and passing of gas. Be kind and professional when addressing this issue with your patient.
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Book Code: MTX1325
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