How do you decide between TCAs, SSRIs, SNRIs, Pregabalin & atypical antipsychotics for neuromodulation in IBS patients?

TCAs are the first-line neuromodulator for IBS pain, with SSRIs, SNRIs, pregabalin, and atypical antipsychotics filling specific niches based on predominant symptoms and IBS subtype.

• TCAs - Strongest evidence for abdominal pain (NNT ~4). Slow GI transit, making them ideal for IBS-D. Start amitriptyline 10 mg at bedtime, titrate to 30 mg. For IBS-C, use less anticholinergic secondary amines (nortriptyline, desipramine).
• SNRIs - Alternative first line for pain, especially with comorbid fibromyalgi...