IBS with Constipation When Laxatives Have Not Achieved Sufficient Bowel Movement Increase

IBS-C is the constipation-predominant subgroup of irritable bowel syndrome — a distinction made specifically to direct therapy. When standard laxative treatment fails to achieve its bowel movement target, a structured second-line protocol in secondary care is the indicated next step.

Clinical scenario

Patients with irritable bowel syndrome with constipation (IBS-C) are subgrouped by their predominant stool pattern to direct therapy. This protocol is for IBS-C patients in secondary care whose first-line laxative regimen has not produced an adequate response.

Prior treatment — target not reached

The preceding regimen — polyethylene glycol or other laxatives with dose titration according to symptoms — did not achieve the treatment goal of an increase in the number of bowel movements. Failure to reach this target triggers escalation to this second-line protocol.

Second-line treatment — Secondary care

This protocol introduces a licensed second-line agent acting on intestinal secretion or motility. The approach draws on a class of secretagogues or, alternatively, a serotonin receptor agonist. The full selection algorithm and clinical decision pathway are available via the protocol link below.

Treatment goals

Improvement in abdominal pain and an increase of at least one complete spontaneous bowel movement per week from baseline.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1136/gutjnl-2021-324598

Patients are subgrouped according to their predominant stool pattern into IBS with diarrhoea (IBS-D), IBS with constipation (IBS-C), IBS with mixed bowel habits (IBS-M) or IBS unclassified (IBS-U), to direct therapy.
Linaclotide, a guanylate cyclase-C agonist, is an efficacious second-line drug for IBS with constipation in secondary care. It is likely to be the most efficacious secretagogue available for IBS with constipation, although diarrhoea is a common side effect (recommendation: strong, quality of evidence: high).
Lubiprostone, a chloride channel activator, is an efficacious second-line drug for IBS with constipation in secondary care. This secretagogue is less likely to cause diarrhoea than others. However, patients should be warned that nausea is a frequent side effect (recommendation: strong, quality of evidence: moderate).
Plecanatide, another guanylate cyclase-C agonist, is an efficacious second-line drug for IBS with constipation in secondary care. Diarrhoea is a common side effect and is no less likely than with linaclotide or tenapanor. Although the drug is licensed for IBS with constipation in the USA, it is not yet available for this indication in many countries (recommendation: strong, quality of evidence: high).
Tenapanor, a sodium-hydrogen exchange inhibitor, is an efficacious second-line drug for IBS with constipation in secondary care. Again, diarrhoea is a frequent side effect. Although the drug is licensed for IBS with constipation in the USA, it is not yet available for this indication in many countries (recommendation: strong, quality of evidence: high).
Tegaserod, a 5-Hydroxytryptamine 4 receptor agonist, is an efficacious second-line drug for IBS with constipation in secondary care but is unavailable outside the USA. Diarrhoea is a common side effect (recommendation: strong, quality of evidence: moderate).

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