From the Guidelines
Treatment of IBS-C should start with lifestyle modifications and progress to medications like linaclotide, which is recommended by the AGA due to its high certainty of evidence and strong recommendation 1.
Initial Approach
When managing IBS-C, it's crucial to begin with non-pharmacological interventions. This includes dietary adjustments such as increasing fiber intake to 25-30g daily, ensuring adequate hydration with at least 8 glasses of water daily, and promoting regular physical activity. Soluble fiber supplements like psyllium (Metamucil) can be beneficial, starting at 3-6g daily.
Pharmacological Management
For persistent symptoms, over-the-counter osmotic laxatives such as polyethylene glycol (MiraLAX, 17g daily) or magnesium citrate can provide relief. If these measures are insufficient, prescription medications like linaclotide (Linzess, 145-290mcg once daily) are recommended due to their effectiveness in increasing intestinal fluid secretion and accelerating transit time 1. Other options include plecanatide (Trulance, 3mg once daily) and lubiprostone (Amitiza, 8mcg twice daily), although the recommendation for lubiprostone is conditional with moderate certainty 1.
Addressing Abdominal Pain and Psychological Comorbidity
Antispasmodics like dicyclomine (10-20mg three to four times daily) can help with associated abdominal pain. Additionally, stress management techniques such as cognitive behavioral therapy, mindfulness, or yoga are beneficial as stress often exacerbates IBS symptoms 1. Central neuromodulation with tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) can be considered for abdominal pain, with TCAs being the first choice due to their demonstrated benefit in reducing abdominal pain compared to placebo 1.
Individualized Treatment Approach
Treatment of IBS-C should be individualized, starting with conservative approaches and advancing as needed based on symptom response. Adopting an evidence-based approach and communicating this accurately to patients is vital to ensure patient satisfaction and adherence to treatment plans 1.
From the FDA Drug Label
- 3 Irritable Bowel Syndrome with Constipation Lubiprostone is indicated for the treatment of irritable bowel syndrome with constipation (IBS-C) in women at least 18 years old.
INDICATIONS AND USAGE LINZESS is a guanylate cyclase-C agonist indicated for treatment of: Irritable bowel syndrome with constipation (IBS-C) in adults.
Treatment of IBS-C can be done using:
- Lubiprostone (PO), with a recommended oral dosage of 8 mcg twice daily 2
- Linaclotide (PO), as it is indicated for the treatment of IBS-C in adults 3
From the Research
Treatment Options for IBS-C
- The treatment of Irritable Bowel Syndrome with Constipation (IBS-C) involves various medications, including loperamide, psyllium, bran, lubiprostone, linaclotide, and peppermint oil, which have shown improvements in specific IBS symptoms 4.
- Rifaximin, lubiprostone, linaclotide, fiber supplementation, and peppermint oil have the most reliable evidence supporting their use for the treatment of IBS-C 4.
- Novel pharmacological treatments for IBS-C include lubiprostone and linaclotide, which have been approved for patients with IBS-C 5.
- A systematic review and network meta-analysis found that linaclotide, lubiprostone, tenapanor, and tegaserod were superior to placebo for abdominal bloating in patients with IBS-C 6.
- Linaclotide demonstrated the greatest improvement in abdominal bloating in both pairwise and network meta-analysis 6.
Efficacy and Safety of Treatments
- Prosecretory agents, such as lubiprostone and linaclotide, have shown efficacy and safety in the treatment of IBS-C and chronic idiopathic constipation (CIC) 7.
- Emerging potential treatment options for IBS-C include prucalopride, plecanatide, elobixibat, and tenapanor, which have novel mechanisms of action and may show promise in patients who have not responded to other therapies 7.
- A narrative review of the literature summarized the clinical profiles of efficacy, safety, and tolerability of prescription drugs for IBS-C, including linaclotide, lubiprostone, plecanatide, tegaserod, and tenapanor 8.
Prescription Drug Treatment Options
- There are eight prescription drugs approved for use in IBS in the USA, including five drugs for IBS-C: linaclotide, lubiprostone, plecanatide, tegaserod, and tenapanor 8.
- Choosing among the various treatment options requires attention to patient preferences, clinical outcomes, and costs associated with treatment 8.