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Treatment Table 7. Tricyclic Antidepressants • Choose agent by symptoms, side effects, cost and comorbidities • Initiate at 10-25 mg at bedtime • Escalate prn by 25%-50% every 1-2 weeks as tolerated • Consider changing agent if no benefit by 6-8 weeks • Taper when stopping Table 8. Treatment Options for Pain and/or Bloating Drug (Brand) Dose Antispasmodics (2C) ) Hyoscyamine sulfate (eg, Levsin® Dicyclomine (eg, Bentyl® ) Clidinium + chlordiazepoxide (eg, Librax® ) Hyoscyamine + scopolamine + atropine + phenobarbital (eg, Donnatal® ) Tricyclic antidepressants (1B) (See Table 7) Selective serotonin reuptake inhibitors (SSRIs) (1B) • SSRIs may help in treating functional gastrointestinal disorders for several potential reasons: ▶ They show improved global well-being and some gastrointestinal-specific symptoms (independent of the effects on depression). ▶ They have anxiolytic properties and can target social phobia, agoraphobia, and symptom-related anxiety. Gut-selective antibiotic Rifaximin (Xifaxan® ) Probiotics (2C) Bifidobacterium lactis/ animalis (eg, Activia® yogurt) B. infantis (Align® ) 1 capsule daily Daily • High-quality studies are lacking • Bifidobacteria improve IBS symptoms • Probiotic studies in general have suggested improvement in gas- related symptoms 400-550 mg tid ▶ They may augment the analgesic effects of other agents (tricyclic antidepressants). • Studies demonstrate relief of bloating 0.125 mg sublingually or PO ≤ qid prn 10-20 mg PO bid-qid prn 2.5 mg/5 mg, 1-2 tablets ≤ tid-qid prn 1-2 tablets daily to qid prn Key Points • Limited proven efficacy in IBS but may be helpful for postprandial symptoms • Can be used as needed • Take before meals