From the Guidelines
Irritable Bowel Syndrome with Constipation (IBS-C) management should prioritize soluble fiber supplementation, such as ispaghula, starting at a low dose of 3-4 g/day and gradually increasing, as it is an effective treatment for global symptoms and abdominal pain in IBS, as recommended by the British Society of Gastroenterology guidelines 1.
Key Management Strategies
- Increase soluble fiber intake to improve overall symptoms of IBS-C, particularly abdominal pain and constipation, as supported by the AGA clinical practice update on the role of diet in IBS 1.
- Avoid insoluble fiber, such as wheat bran, as it may exacerbate symptoms, and consider a diet low in fermentable oligosaccharides, disaccharides, and monosaccharides, and polyols (FODMAPs) as a second-line dietary therapy, under the supervision of a trained dietitian 1.
- Probiotics may be considered as an adjunctive treatment, but it is essential to advise patients to take them for up to 12 weeks and discontinue if there is no improvement in symptoms, due to the limited evidence supporting their efficacy 1.
Lifestyle Modifications
- Regular exercise, such as 30 minutes of physical activity most days, is recommended, although the quality of evidence is weak 1.
- Stay hydrated with at least 8 glasses of water daily to help soften stool and improve bowel movements.
- Stress management techniques, such as meditation or yoga, can also help alleviate IBS symptoms by addressing gut-brain interactions.
Medications
- Loperamide may be considered for diarrhea-predominant IBS, but its use in IBS-C is limited due to potential side effects, such as constipation, and the lack of strong evidence supporting its efficacy in this subtype 1.
- Other medications, such as osmotic laxatives, like polyethylene glycol (MiraLAX), and prescription options, like linaclotide (Linzess), plecanatide (Trulance), or lubiprostone (Amitiza), may be considered for the treatment of IBS-C, but their use should be guided by individual patient needs and response to treatment.
From the FDA Drug Label
The most common adverse reactions (>4%) in IBS-C were not explicitly stated in the provided text, but the following adverse reactions were reported in clinical trials of adults with IBS-C: Nausea: Approximately 29% of patients who received lubiprostone experienced nausea in CIC trials, but the rate for IBS-C was not provided. Diarrhea: Approximately 12% of patients who received lubiprostone experienced diarrhea in CIC trials, but the rate for IBS-C was not provided.
The data described below reflect exposure to lubiprostone 8 mcg twice daily in 1011 patients with IBS-C for up to 12 months and from 435 patients receiving placebo twice daily for up to 16 weeks
Management of IBS-C symptoms with lubiprostone may involve monitoring for adverse reactions such as nausea and diarrhea.
- Nausea and diarrhea are common adverse reactions associated with lubiprostone.
- Patients should be instructed to contact their healthcare provider if they experience any adverse reactions. 2
From the Research
IBS-C Symptoms
- IBS-C is characterized by abdominal pain associated with defecation or a change in bowel habits 3, 4, 5
- Symptoms of IBS-C include constipation, abdominal pain, and discomfort 3, 4, 5
- The pathogenesis of IBS-C is multifactorial and complex, involving factors such as abnormal GI motility, low-grade inflammation, and increased epithelial permeability 6
Management of IBS-C
- Initial management of IBS-C should include simple lifestyle and dietary advice, discussion of the possible benefit of some probiotics, and consideration of a low FODMAP diet 5
- Antispasmodics and peppermint oil can be used first-line for the treatment of abdominal pain 5
- Loperamide and laxatives can be used first-line for treating diarrhea and constipation, respectively 5
- Lubiprostone and linaclotide are prosecretory agents that have been shown to be effective in the treatment of IBS-C and chronic idiopathic constipation 3, 4, 7
- Emerging potential treatment options include prucalopride, plecanatide, elobixibat, and tenapanor 7
Dietary Management
- Fiber intake, especially soluble fiber such as inulin, may have a positive effect on symptoms of IBS-C 6
- Functional foods, prebiotics, probiotics, and symbiotics may also have a beneficial effect on symptoms and microbiota in IBS-C subjects 6
- There is no specific diet for IBS-C, but a balanced diet that includes a variety of fruits, vegetables, and whole grains may help to alleviate symptoms 6
Pharmacological Management
- Lubiprostone is an oral bicyclic fatty acid that selectively activates type 2 chloride channels in the apical membrane of the intestinal epithelial cells, inducing peristalsis and laxation 3
- Linaclotide is a guanylate cyclase-C agonist that increases intestinal fluid secretion and motility 7
- Rifaximin is an antibiotic that has been shown to be effective in the treatment of IBS-C, particularly in patients with bloating and abdominal pain 4