Figure 1.

Suggested algorithm for the management of irritable bowel syndrome. CBT, cognitive behavioural therapy; FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides and polyols; IBS, irritable bowel syndrome; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; 5-HT₃, 5-hydroxytryptamine-₃. *As per NICE IBS dietary advice sheet, plus consider ispaghula husk. +Tricyclic antidepressants should be first choice, starting at a dose of 10mg at night, and titrating slowly (e.g. by 10mg per week) according to response and tolerability. Continue for at least 6 months if patient reports symptomatic response. ‡Review efficacy after 3 months of treatment, and discontinue if no response.