Treatment of Irritable Bowel Syndrome with Constipation (IBS-C)

Initial Management: Lifestyle and Dietary Interventions

The American Gastroenterological Association recommends starting with soluble fiber supplementation (ispaghula/psyllium) at 3-4 g/day and gradually increasing, avoiding insoluble fiber like wheat bran which worsens symptoms 1, 2
Prescribe regular physical activity to all IBS-C patients, as exercise provides significant benefits for symptom management 1, 2
Establish regular time for defecation and ensure adequate sleep hygiene 2
Maintain a balanced diet with appropriate fiber intake 1, 3

The American College of Gastroenterology recommends using antispasmodics with anticholinergic properties (dicyclomine) as first-line therapy for abdominal pain, particularly when symptoms are meal-related 1, 2, 3
Peppermint oil may be useful as an alternative antispasmodic, though evidence is more limited 1, 2

Consider IBS-specific cognitive behavioral therapy or gut-directed hypnotherapy for symptoms refractory to pharmacological treatment 1, 2
Biofeedback may be especially helpful for disordered defecation 1, 3

Review treatment efficacy after 3 months and discontinue ineffective medications 1, 2

Do not pursue extensive testing once IBS-C diagnosis is established in patients under 45 years meeting diagnostic criteria without alarm features 1, 2
Avoid insoluble fiber (wheat bran) as it worsens symptoms 2
Do not recommend IgG-based food allergy testing, as true food allergy is rare in IBS 2

Refer to gastroenterology dietitian if patient consumes considerable intake of foods that trigger IBS symptoms, or has dietary deficits or nutrition red flags 1, 2
Refer to gastropsychologist if IBS symptoms or their impact are moderate to severe, patient accepts that symptoms are related to gut-brain dysregulation, and has time to devote to learning new coping strategies 1