Dec. 15, 2022
For purposes of government medication approval, chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) are thought of as separate disorders. But in reality, there is a lot of overlap. Both are associated with significant medical, social and economic burdens. As of 2021, CIC affects 11.7% and IBS-C affects 1.3% of the global population.
In a review article published in 2022 in The American Journal of Gastroenterology, co-authors Lucinda A. Harris, M.D., and Christopher H. Chang, M.D., Ph.D., sought to shed light on the burdens experienced by individuals with CIC and IBS-C. This article discusses the way patients experience constipation symptoms, how these symptoms impact health-related quality of life and the challenges that patients encounter when seeking effective care for these conditions. Dr. Harris is a gastroenterologist at Mayo Clinic's campus in Arizona.
Symptoms and diagnosis
According to Dr. Harris, patients with IBS-C and CIC can present with overlapping symptoms, which include abdominal pain, difficulty with defecation, bloating and distention. Symptoms associated with IBS-C include visceral hyperalgesia and allodynia, known collectively as visceral hypersensitivity. Pain is the predominant symptom of IBS-C, using Rome IV criteria.
Patients with CIC are generally diagnosed with this condition when they do not meet the full criteria for IBS-C. Individuals with this diagnosis do not identify pain as their predominant symptom.
"Some experts believe that IBS-C and CIC exist along a continuum, where patients can fluctuate between either diagnosis," says Dr. Harris. "This makes differentiating between the two conditions difficult. However, because multiple treatment options are indicated and approved for both conditions, differentiation between IBS-C and CIC may not be crucial."
Patient perspectives on CIC and IBS-C
Two studies that provide useful information about patient perspectives on the burdens associated with CIC and IBS-C are the BURDEN-CIC and BURDEN-IBS studies, published in Advances in Therapy in 2017 and 2018, respectively.
Dr. Harris, a co-author on both study publications, explains that the BURDEN studies examined the experiences and ongoing needs of patients with CIC and IBS-C and assessed how those factors align with the perceptions and needs of health care providers (HCPs) who treat patients with these conditions. Researchers used an online questionnaire to survey 1,223 individuals with CIC and 1,311 individuals with IBS-C.
According to Dr. Harris, the BURDEN studies and other published research suggest that patients with these diagnoses often experience feelings of frustration, shame, embarrassment, helplessness and social withdrawal. In addition, the symptoms experienced can negatively affect the patient's self-image.
Despite these impacts, only one-third of individuals with these conditions consult an HCP about their constipation, and only one-fifth of individuals who do seek help feel that their symptoms are well managed. Fewer than half the individuals with these conditions take medications, and many rely on over-the-counter therapies rather than prescription therapies.
According to Dr. Harris, the decision about whether to report symptoms and seek medical care also can be influenced by diagnosis, sex, ethnicity and other factors. "Researchers have observed several differences associated with a patient's sex, ethnicity or cultural background and other demographics that influence who seeks medical care for these conditions."
The challenges in diagnosing CIC and IBS-C described earlier sometimes means that patients who do seek medical care may encounter multiple obstacles to achieving optimal care. When a definitive diagnosis isn't reached, patients can experience increased anxiety, which can lead to multiple consultations and overuse of invasive testing. Lack of awareness of available treatment options among patients also may increase their tendency to accept their symptoms. And researchers have observed that there is a subset of patients who won't agree with symptom-based diagnoses, which can affect their adherence to treatment and cause them to request multiple consultations with health care providers.
"We know that involving our patients in their treatment decisions improves their adherence and overall satisfaction. So health care providers need to provide clear explanations of these diagnoses and actively seek to understand and address patients' concerns and treatment goals," explains Dr. Harris.
Finally, Dr. Harris notes that some restrictions imposed by insurance providers can cause treatment cost, rather than clinical efficacy, to guide treatment choices.
"If we are truly committed to minimizing the burden of CIC and IBS-C symptoms," says Dr. Harris, "we need to take a more patient-centered approach that recognizes the multiple factors that can shape a patient's experience and clinical outcomes. Think about that patient trying to empty their bowel over several hours in the morning, or the patient who complains of increased bloating because they have not had a bowel movement in days. This means clinicians need to address comorbidities, quality-of-life impacts, demographic and cultural differences, previous medical experiences, and available therapies. If we identify and address these issues, we can establish a much clearer understanding of our patients' experiences and develop individualized treatment strategies that can alleviate these burdens."
For more information
Harris LA, et al. Burden of constipation: Looking beyond bowel movements. The American Journal of Gastroenterology. 2022;117:S2.
Harris LA, et al. The better understanding and recognition of the disconnects, experiences, and needs of patients with chronic idiopathic constipation (BURDEN-CIC) study: Results of an online questionnaire. Advances in Therapy. 2017;34:2661.
Quigley EMM, et al. The better understanding and recognition of the disconnects, experiences, and needs of patients with irritable bowel syndrome with constipation (BURDEN IBS-C) study: Results of an online questionnaire. Advances in Therapy. 2018;35:967.
Refer a patient to Mayo Clinic.