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Irritable Bowel Syndrome (IBS) and breastfeeding

By Wendy Jones in Fact Sheet on 17 October 2023.

Irritable bowel disease causes distress to many. This factsheet has been developed from my books and particularly Breastfeeding and Chronic Medical Conditions available from Amazon. I hope it helps.

wendy@breastfeeding-and-medication.co.uk

In October 2023 a new paper (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01725-7/fulltext) was published on the use of low dose amitriptyline to treat IBS if anti smasmodic agents have failed to control symptoms. Amitriptyline is compatible with breastfeeding but care should be taken co-sleeping as it may cause maternal drowsiness.

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IBS is increasingly managed in primary care, commonly with analgesics and dietary regimes as first-line approaches. Although psychotropic drugs such as tricyclic antidepressants and selective serotonin reuptake inhibitors have shown effectiveness as second-line treatment for IBS, their use is not widespread in primary practice. Tricyclic antidepressants, such as amitriptyline or desipramine, are advocated at low doses to relieve IBS symptoms, but so far there is no solid evidence for their effectiveness and safety in primary care.

Alexander C Ford and colleagues conducted the ATLANTIS randomised controlled trial in adult patients with IBS in primary care in the UK, comparing amitriptyline at doses of 10 mg to 30 mg once daily with placebo. Patients were required to meet Rome IV diagnostic criteria, and have ongoing symptoms with an IBS Severity Scoring System (IBS-SSS) score of greater than or equal to 75 despite dietary changes and first-line treatments. Patients, general practitioners, and the research team were masked for the trial medication, which is essential in IBS research, given the high placebo response in the condition. Symptom-based, subjective, and social outcome measures, including anxiety and depression, were used, in line with the broad disease effect of IBS. The primary endpoint was the IBS-SSS score at 6 months. Outcomes were measured at months 3, 6, and 12, but the month 12 outcomes had a lower sample size than intended owing to follow-up being curtailed by the COVID-19 pandemic.

The results of the ATLANTIS trial are robust and consistent, and demonstrate that a low dose tricyclic antidepressant can be effectively and safely applied for patients with IBS in primary care, as an option, not as standard treatment. Optimal IBS management requires a personalised approach, with treatment steps dependent on the type of IBS symptoms, disease history, treatment response in the past, and sensitivity to side-effects.

Irritable bowel syndrome can be treated during breastfeeding. Some remedies suit some mothers more than other remedies. There is also a significant body of research that indicates that CBT is effective in reducing IBS symptoms of abdominal pain, diarrhoea, and constipation.

Introduction

Irritable bowel syndrome (IBS) is a common, chronic, relapsing, and often life-long condition, mainly affecting people aged between 20 and 30 years. It is more common in women. Symptoms include abdominal pain or discomfort, either diarrhoea or constipation (or both alternating) and bloating. The treatment of IBS is focused on symptom control, in order to improve quality of life. It occurs in 10-20% of the population and again is more common in women than men.

Diagnosis

According to NICE CG 61 (Irritable bowel syndrome in adults: diagnosis and management) in order to diagnose IBS:

Patients must give at least a six-month history of either:

• Abdominal pain or discomfort.

• Bloating.

• Change in bowel habit. Consider positively diagnosing IBS only if abdominal pain is either relieved by defecation or associated with altered bowel frequency or stool form.

AND at least 2 of the following are present:

Altered passage of stool (straining, urgency, incomplete evacuation).

• Abdominal bloating (women >men), distention tension or hardness.

• Symptoms aggravated by eating.

• Passage of mucus rectally.

Before diagnosis, blood tests and a colonoscopy are commonly undertaken to rule out other conditions which may, at least initially, present with similar symptoms e.g., IBD.

Medication

The categories of drugs involved reduce spasms, control constipation or diarrhoea (see section on bowel issues). Symptoms are frequently accompanied by depression.

Dicycloverine (Dicyclomine) (Merbentyl ™ Kolanticon ™). In the past this drug was used to treat colic in babies but following reports of breathing difficulties, its license for use in infants under 6 months was withdrawn. The adverse reactions occurred in babies under the age of 6 weeks and involved sudden reactions following administration of the drug via a spoon. All children recovered normally (Williams 1994, Edwards 1984, Spoudea 1984). There is also a single case report of a similar reaction in a 12-day old, breastfed baby whose mother took this drug (personal communication reported in Briggs 2005), so it is a drug best avoided in lactation since there are alternative preparations available.

Hyoscine (Buscopan ™) is often the drug preferred by patients with IBS. No levels in breastmilk have been reported from studies. It is licensed at half the adult dose for children over 6 years (10 milligrams three times daily) so the amount passing into breastmilk is likely to be safe.

Alverine (Relaxyl™, Spasmonal™) is widely used to treat symptoms of irritable bowel syndrome but one study shows that it was no better than placebo in providing relief of symptoms (Mitchell 2002). It is licensed for use in patients over the age of 12 years. There is no information on its passage into breastmilk. Avoid if possible.

Mebeverine (Colofac™) should be taken 20 minutes before meals for maximum effect. It is licensed for use in children above the age of three so levels passing into breastmilk are likely to be safe.

Peppermint Oil (Colpermin ™) capsules are used to relieve spasms associated with IBS but should be swallowed whole, half to one hour before food to avoid irritation of the oesophagus. There is some evidence to support the value of this product in therapy (Pittler 1998, Grigoleit 2005). Peppermint oil is believed to undergo rapid first pass metabolism so levels in breastmilk will be low. There have been anecdotal reports in internet discussions by lactation specialists in the US that it can reduce milk supply but there are currently no studies to prove or disprove these.

References

• De Wit N Low-dose amitriptyline in irritable bowel syndrome: ready for primary care? The Lancet Oct 2023.

Edwards PDL. Dicyclomine in babies. BMJ 1984; 288: 1230. Reported as personal communication in Briggs GG, Freeman RK, and Yaffe SJ. Drugs in pregnancy and lactation, 7th ed. Baltimore. Williams & Wilkins. 2005

• Grigoleit H-G, Grigoleit P. Peppermint oil in irritable bowel syndrome. Phytomedicine 2005; 12: 601-6

• Hale T W Medications and Mothers Milk

• Jones W Breastfeeding and Medication (Routledge 2018)

• LactMed database http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACTMED

• Mitchell SA, Mee AS, Smith GD, Palmer KR, Chapman RW. Alverine citrate fails to relieve the symptoms of irritable bowel syndrome: results of a double-blind, randomized, placebo-controlled trial. Aliment Pharmacol Ther. 2002 16(6):1187-95.

• NICE QS 114 (2016) Irritable bowel syndrome in adults

• Pittler MH, Ernst E. Peppermint oil for irritable bowel syndrome: a critical review and meta-analysis. Am J Gastroenterol 1998; 93: 1131-5.

• Spoudeas H, Shribman S. Dicyclomine in babies. BMJ 1984; 288: 1230

• Williams J, Watkin-Jones R. Dicyclomine: worrying symptoms associated with its use in some small babies. BMJ 1984; 288: 90