Diagnosis and treatment of irritable bowel syndrome with predominant constipation in the primary-care setting: focus on linaclotide

Figures & data

Figure 1 Burden of irritable bowel syndrome (IBS).

Note: The submerged portion of the iceberg represents undiagnosed IBS in the community, while the tip (not submerged) represents IBS seen in clinical practice.

Table 1 Frequent comorbidities in IBS seen in primary care

Comorbidity	Comments
Fibromyalgia	Most well-recognized and frequently encountered comorbidity in IBS patients;^Citation53,Citation54 can be present in up to 33% of IBS patients.^Citation55
Chronic fatigue syndrome	Presence of chronic fatigue syndrome in IBS has been found to be about 14%.^Citation55
Chronic pelvic pain	Significant association with IBS reported in a large study;^Citation54 nearly 35% of women with IBS found to experience chronic pelvic pain.^Citation55
Temporomandibular joint disorder	A small study found that 16% of IBS patients had temporomandibular joint disorder.^Citation54
Major depression	Most frequent psychiatric comorbidity associated with IBS.^Citation55,Citation56
Generalized anxiety disorder	Second-commonest psychiatric comorbidity seen in IBS patients.^Citation55,Citation57

Abbreviation: IBS, irritable bowel syndrome.

Table 2 Commonly used therapies for IBS-C

Treatment modality	Evidence quality	Comments
Fiber: psyllium	Moderate	May cause bloating and flatulence; may increase abdominal pain.
Laxative: polyethylene glycol (macrogol)	Very low	Bloating, cramping, and diarrhea if taken in excess; may not be better than placebo in reducing abdominal pain;^Citation58 limited evidence from RCTs.
Antidepressants: TCAs and SSRIs	High	SSRIs generally have a favorable side-effect profile when compared to TCAs (dry mouth, sedation, constipation, flushing).
Prosecretory agent: lubiprostone	Moderate	Nausea is the predominant side effect. In the US, only 8 μg dose is approved by the FDA for women only.^Citation48
Prosecretory agent: linaclotide	High	Diarrhea is the most common adverse event.
Psychological therapy: CBT, mindfulness therapy, and hypnotherapy	Very low	CBT is the most widely studied psychotherapy for IBS, and may be first-line behavioral intervention for IBS-C.^Citation33 No behavioral modification is likely better than placebo.

Note: Data from Chey et al.⁵⁹

Abbreviations: CBT, cognitive behavior therapy; IBS-C, irritable bowel syndrome with constipation; RCTs, randomized controlled trials; SSRIs, selective serotonin-reuptake inhibitors; TCAs, tricyclic antidepressants.

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