IBS-C Review Emphasizes Multisymptom Management Beyond Constipation and Pain

Key Clinical Summary

• Irritable bowel syndrome with constipation (IBS-C) should be diagnosed using a positive, symptom-based approach rather than by exclusion, with careful differentiation from chronic idiopathic constipation (CIC) and evaluation for alarm features.
• Abdominal discomfort, bloating, and straining are among the most bothersome symptoms for many patients and should be routinely assessed alongside abdominal pain and bowel movement frequency when evaluating treatment response.
• FDA-approved therapies including plecanatide, linaclotide, lubiprostone, and tenapanor have demonstrated efficacy across multiple IBS-C symptoms, supporting a patient-centered, multisymptom treatment strategy.

Irritable bowel syndrome with constipation (IBS-C) management should extend beyond improving abdominal pain and bowel movement frequency to address the broader symptom burden that affects patients' quality of life, according to a narrative review published in Advances in Therapy. The review synthesizes current evidence on diagnosis, differentiation from chronic idiopathic constipation (CIC), and pharmacologic and nonpharmacologic approaches that target multiple gastrointestinal symptoms simultaneously.

Study Findings 

Approximately one-third of patients with irritable bowel syndrome have the constipation-predominant subtype. While the Rome IV criteria define IBS-C by recurrent abdominal pain associated with altered bowel habits, patients frequently report abdominal discomfort, bloating, and straining, symptoms that many consider more bothersome than constipation itself. These symptoms contribute substantially to impaired health-related quality of life, reduced work productivity, and psychosocial distress.

The authors emphasize that IBS-C should be diagnosed using a positive diagnostic strategy, as recommended by the American College of Gastroenterology, rather than through extensive exclusionary testing. Colonoscopy is generally unnecessary in patients younger than 45 years without alarm features, and distinguishing IBS-C from CIC is essential because abdominal pain is more frequent and severe in IBS-C, which is also associated with greater symptom burden and more psychological comorbidities.

The review summarizes pivotal phase 3 data supporting currently approved therapies. Plecanatide achieved the FDA composite responder endpoint in 21.5% to 30.2% of treated patients compared with 14.2% to 17.8% receiving placebo (P<0.01). Linaclotide produced responder rates of 33.6% versus 21.0% in a 12-week trial and 33.7% versus 13.9% during the first 12 weeks of a 26-week trial (both P<0.0001). Lubiprostone demonstrated significantly higher overall responder rates than placebo (17.9% vs 10.1%; P=0.001), while tenapanor achieved responder rates of 27.0% versus 18.7% in T3MPO-1 (P=0.02) and 36.5% versus 23.7% during the first 12 weeks of T3MPO-2 (P<0.001).

Beyond the traditional endpoints of abdominal pain and complete spontaneous bowel movements, the review highlights evidence supporting multisymptom composite endpoints that incorporate bloating, abdominal discomfort, and straining. Post hoc analyses showed plecanatide, linaclotide, and tenapanor improved composite abdominal symptom scores, supporting a broader assessment of therapeutic benefit.

Clinical Implications

The authors argue that evaluating treatment success solely by bowel movement frequency and abdominal pain may underestimate clinically meaningful improvement. Because bloating, abdominal discomfort, and straining often drive healthcare utilization and diminish quality of life, these symptoms should be routinely assessed during follow-up and incorporated into treatment decisions.

Management should be individualized according to each patient's most bothersome symptoms. First-line therapy includes FDA-approved secretagogues and the sodium/hydrogen exchanger 3 inhibitor tenapanor. Patients with persistent symptoms may benefit from an integrated approach incorporating neuromodulators, dietary modification such as a low-FODMAP diet, brain-gut behavioral therapies, and, when intestinal methanogen overgrowth is identified by breath testing, targeted antibiotic therapy. The review also emphasizes reviewing medications that may worsen constipation and engaging patients in shared decision-making to establish realistic treatment expectations for this chronic condition.

Expert Commentary

"The frequency and negative impacts" of abdominal discomfort, bloating, and straining provide "a clinical rationale for broadened composite efficacy endpoints for treatment evaluation," the authors write, concluding that optimal IBS-C management requires a timely positive diagnosis, personalized treatment targeting patients' most bothersome symptoms, and collaborative decision-making between patients and healthcare providers.

Effective IBS-C management requires recognizing that the disorder extends beyond constipation and abdominal pain. By emphasizing multisymptom assessment, evidence-based pharmacologic therapy, and individualized care plans, the review supports a more comprehensive approach that better aligns treatment goals with the symptoms patients find most burdensome.

Reference 

Shah ED, Sharma A, Curren N, Laitman AP, Staller K. Irritable bowel syndrome with constipation: diagnosis and multisymptom management beyond abdominal pain and bowel movement frequency: a review. Adv Ther. Published online ahead of print June 12, 2026. DOI: 10.1007/s12325-026-03645-w