Irritable Bowel Syndrome with Constipation: Diagnosis and Multisymptom Management Beyond Abdominal Pain and Bowel...

Approximately one-third of patients with irritable bowel syndrome (IBS) have IBS with constipation (IBS-C). Cardinal symptoms of IBS-C are abdominal pain and reduced bowel movement frequency. However, additional symptoms, including abdominal discomfort, bloating, and straining, are prevalent and are some of the most bothersome symptoms for patients, providing a clinical rationale for efficacy assessments that encompass simultaneous improvement in multiple IBS-C symptoms. This review highlights the diagnostic approach to IBS-C, including differentiation from chronic idiopathic constipation (CIC), and expands on data supporting multisymptom treatment beyond cardinal symptoms. Several medications are indicated for IBS-C, including secretagogues such as guanylate cyclase C agonists (plecanatide, linaclotide) and chloride channel activators (lubiprostone [women only]), as well as sodium/hydrogen exchanger 3 (NHE3) inhibitors (tenapanor). An integrated approach to treatment of IBS-C, particularly in patients with persistent symptoms after treatment with first-line secretagogues or NHE3 inhibitors, may include neuromodulators, appropriate antibiotic regimens in those with intestinal methanogen overgrowth (IMO), and/or nonpharmacologic approaches including dietary interventions and brain-gut behavioral therapies. Effective treatment plans for IBS-C should target the most bothersome symptoms, including a collaborative discussion of risks/benefits of various treatments, culminating in an agreement on a path forward between the patient and healthcare provider.