From the Guidelines
For a 52-year-old male with new-onset constipation and a normal colonoscopy, I strongly recommend starting with a trial of linaclotide (Linzess) before proceeding to additional imaging. Linaclotide should be initiated at 145 mcg once daily, taken on an empty stomach at least 30 minutes before the first meal of the day, as recommended by the AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with constipation 1. The medication works by increasing intestinal fluid secretion and motility, which can help relieve constipation. If the patient doesn't respond adequately after 2-4 weeks, the dose can be increased to 290 mcg daily. Common side effects include diarrhea, abdominal pain, and flatulence. Since the colonoscopy was normal, ruling out structural causes of constipation, a functional cause is more likely, making linaclotide an appropriate first-line therapy.
Some key points to consider when prescribing linaclotide include:
- The patient should be counseled on the potential side effects of the medication, including diarrhea, abdominal pain, and flatulence.
- Lifestyle modifications, such as increased fluid intake, dietary fiber, and regular physical activity, should be recommended to complement pharmacological treatment.
- Additional imaging, such as abdominal CT, would be warranted only if there are concerning features like unintentional weight loss, blood in stool, severe abdominal pain, or if symptoms persist despite adequate medical therapy.
- The British Society of Gastroenterology guidelines on the management of irritable bowel syndrome also support the use of linaclotide as a second-line drug for IBS with constipation, with a strong recommendation and high quality of evidence 1.
Overall, the current evidence supports the use of linaclotide as a first-line treatment for constipation in patients with a normal colonoscopy, and it is essential to weigh the potential benefits and risks of the medication when making treatment decisions.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation and Management of Constipation
- The patient's symptoms of new constipation and normal colonoscopy results suggest that further evaluation and management of constipation are necessary 2, 3.
- The initial evaluation of constipation begins with a focused history of the patient's bowel habit, medications, diet, physical activity, and an anorectal examination 2.
- In the absence of alarm signs, diagnostic testing for constipation is not routinely recommended in the initial evaluation 2.
Treatment Options for Constipation
- First-line management includes lifestyle changes such as increased physical activity, high-fiber diets, adequate fluid intake, and bowel management techniques 2, 3.
- Pharmacologic therapies, including stool softeners and agents that increase intestinal transit, are available for the treatment of constipation 2, 3.
- Linaclotide is a novel compound approved for the treatment of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) 4, 5.
- Linaclotide has been shown to be effective in treating CIC and IBS-C, with a favorable safety profile and minimal systemic bioavailability 4, 5, 6.
Considerations for Linaclotide Treatment
- Linaclotide is appropriate as a first-line prescription treatment for IBS-C, but for CIC, osmotic or stimulant laxatives should be tried prior to using linaclotide due to their lower cost 4.
- The most common treatment-emergent adverse event associated with linaclotide is diarrhea, which is typically mild or moderate 6.
- The decision to start linaclotide or have imaging should be based on the patient's individual symptoms, medical history, and response to initial management 2, 3.