What are the management options for Irritable Bowel Syndrome (IBS) with constipation?

From the Guidelines

Management of IBS with constipation should prioritize a multi-faceted approach, including lifestyle modifications, dietary changes, and medications, with linaclotide being a recommended pharmacological option. This approach is based on the most recent and highest quality evidence, including the 2022 AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with constipation 1.

Lifestyle Modifications

Lifestyle modifications are essential in managing IBS with constipation. These include:

• Increasing physical activity, as recommended by the British Society of Gastroenterology guidelines 1
• Adequate hydration, with at least 8 cups of water daily
• Regular meals and avoiding long gaps between eating, as suggested by the AGA clinical practice update on the role of diet in irritable bowel syndrome 1

Dietary Changes

Dietary changes play a crucial role in managing IBS with constipation. These include:

• Increasing dietary fiber, but with caution and under supervision, as high fiber intake can exacerbate symptoms in some patients 1
• Following a low-FODMAP diet, which may help reduce symptoms in some patients, although the evidence is not strong 1
• Avoiding foods that can trigger symptoms, such as those high in resistant starch or insoluble fiber 1

Medications

Medications can be effective in managing IBS with constipation. These include:

• Osmotic laxatives, such as polyethylene glycol, which can help increase stool frequency 1
• Secretagogues, such as linaclotide, which can increase intestinal fluid secretion and accelerate transit 1
• Lubiprostone and plecanatide, which work similarly to linaclotide and can be effective in managing constipation in IBS patients 1
• Antispasmodics, such as dicyclomine, which can help relieve abdominal pain 1
• Tricyclic antidepressants, which can help alter gut motility and modulate pain perception 1

Individualized Approach

Treatment should be individualized based on symptom severity and patient response, often requiring a combination approach for optimal management. The most recent and highest quality evidence should guide treatment decisions, with linaclotide being a recommended pharmacological option for patients with IBS with constipation 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Irritable Bowel Syndrome with Constipation (IBS-C) in Adults

The efficacy of LINZESS for the treatment of IBS-C was established in two double-blind, placebo-controlled, randomized, multicenter trials in adult patients

1.1 Chronic Idiopathic Constipation in Adults Lubiprostone capsules are indicated for the treatment of chronic idiopathic constipation (CIC) in adults.

1. 3 Irritable Bowel Syndrome with Constipation Lubiprostone capsules are indicated for the treatment of irritable bowel syndrome with constipation (IBS-C) in women at least 18 years old.

Management options for IBS with constipation include:

• Linaclotide (LINZESS): indicated for the treatment of IBS-C in adults 2
• Lubiprostone: indicated for the treatment of IBS-C in women at least 18 years old 3

From the Research

Management Options for IBS with Constipation

The management of Irritable Bowel Syndrome (IBS) with constipation involves a variety of approaches, including dietary interventions, medications, and lifestyle modifications.

• Dietary Interventions:
  • Fiber supplementation has been shown to be beneficial in mild to moderate constipation and IBS-C 4, 5.
  • A FODMAP-restricted diet may be effective in short-term management of selected patients with IBS and IBS-C 5.
• Medications:
  • Lubiprostone, linaclotide, and fiber supplementation have reliable evidence supporting their use for the treatment of IBS with constipation 6.
  • Other medications such as psyllium, bran, and peppermint oil may also be beneficial 6, 7.
• Lifestyle Modifications:
  • Increasing physical activity and managing stress may help alleviate symptoms of IBS with constipation.
  • Adequate fluid intake is also essential to prevent constipation.
• Treatment Approach:
  • Treatment should be individualized and focused on the predominant symptom 8.
  • A tailored approach based on the patient's symptom complex is recommended 8, 7.

Key Considerations

• The efficacy of medications for IBS with constipation can vary, and additional studies are needed to better define their place in therapy 6.
• Psychological treatments, including hypnotherapy, may play an important role in relieving pain and other symptoms 7.
• Further research is needed to establish the long-term efficacy and safety of FODMAP-restricted diets and other treatments for IBS with constipation 5.