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Linaclotide

Linaclotide is a synthetic 14-amino acid that functions as a guanylate cyclase-C (GC-C) receptor agonist, primarily used to treat with (IBS-C) and chronic idiopathic (CIC) in adults, as well as (FC) in pediatric patients aged 6 years and older and IBS-C in pediatric patients aged 7 years and older. Approved by the U.S. (FDA) in 2012 for adult use under the brand name Linzess, it was the first in its to address these conditions by enhancing intestinal and while alleviating . In November 2025, the FDA expanded approval to children 7 years and older with IBS-C, marking the first such treatment for this pediatric population based on clinical trials demonstrating significant reductions in and improvements in bowel movement frequency. The drug's mechanism of action involves binding to GC-C receptors on the luminal surface of intestinal enterocytes, which increases intracellular levels of (cGMP). This elevation in cGMP promotes and into the intestinal , leading to increased fluid that softens and accelerates gastrointestinal transit. Additionally, linaclotide reduces signaling by desensitizing nociceptors in the gut, providing relief from the visceral associated with IBS-C. Due to its structure and poor oral absorption, linaclotide acts locally in the intestine with minimal systemic exposure, which contributes to its targeted efficacy and limited off-target effects. Administered as an oral capsule on an empty at least 30 minutes before the first meal of the day, linaclotide is available in doses of 72 mcg, 145 mcg, and 290 mcg. For adults with IBS-C, the recommended dose is 290 mcg once daily, while 145 mcg (or 72 mcg for those with tolerability issues) is used for ; for pediatric patients with , the dose is 72 mcg daily, and for those with IBS-C, it is 145 mcg daily. Contraindications include known or suspected mechanical gastrointestinal obstruction and use in children under 2 years due to risks of severe from . Common adverse effects include , , and , with severe cases potentially leading to that may require dose interruption or discontinuation. Ongoing research explores its potential in off-label applications, such as opioid-induced and prevention, highlighting its broader therapeutic promise.

Medical uses

Indications

Linaclotide is indicated for the treatment of with (IBS-C) in adults and pediatric patients aged 7 years and older. It is also approved for chronic idiopathic (CIC) in adults. In June 2023, the U.S. () expanded the indication to include in pediatric patients aged 6 to 17 years, providing the first approved pharmacologic option for this population. On November 5, 2025, the FDA further expanded approval of linaclotide for to include pediatric patients aged 7 to 17 years, marking it as the first FDA-approved treatment specifically for this subgroup. This approval was supported by data from adult trials and a dedicated pediatric study demonstrating safety and efficacy in improving symptoms in children. Clinical efficacy for these indications is established through pivotal phase 3 trials. For in adults, trials MCP-103-303 and LIN-MD-01 showed that linaclotide significantly increased the weekly frequency of complete spontaneous bowel movements by 2- to 3-fold compared to over 12 weeks, while also improving and reducing straining. In IBS-C, phase 3 trials (LIN-MD-31 and MCP-103-302) demonstrated that linaclotide reduced by approximately 30-50% and increased bowel movement frequency, with over 30% of patients achieving combined responder status for pain relief and bowel symptom improvement versus 20% on . These outcomes highlight linaclotide's role in addressing both bowel and abdominal symptoms central to these disorders. Although linaclotide is primarily used for its approved indications, emerging research explores its potential in other constipation subtypes, such as ; however, such applications remain off-label and lack robust approval-level evidence.

Dosage and administration

Linaclotide is available in oral capsules of 72 mcg, 145 mcg, and 290 mcg strengths. For adults with (IBS-C), the recommended dosage is 290 mcg once daily. For adults with (CIC), the recommended dosage is 145 mcg once daily; a reduced dose of 72 mcg once daily may be used based on individual presentation or tolerability. In November 2025, the U.S. approved linaclotide for use in pediatric patients aged 7 years and older with IBS-C, marking the first approval for this indication in children. The recommended dosage for these patients is 145 mcg orally once daily. Linaclotide is also approved for in pediatric patients aged 6 to 17 years at a dosage of 72 mcg once daily. Linaclotide should be taken on an empty at least 30 minutes before the first meal of the day, at approximately the same time each day. Capsules must be swallowed whole and should not be crushed or chewed, as this may affect the release of the medication. For patients who have difficulty swallowing capsules, the contents may be sprinkled on 1 of room-temperature and consumed immediately without chewing, or mixed with 30 mL of room-temperature , swirled for at least 20 seconds, and swallowed promptly. Administration via nasogastric or tube is possible by mixing the capsule contents with 30 mL of and flushing with an additional 10 mL of . If a dose is missed, it should be skipped, and the next dose taken at the regularly scheduled time; double dosing should be avoided. Capsules should be stored at controlled (20°C to 25°C or 68°F to 77°F), with excursions permitted between 15°C and 30°C (59°F and 86°F), in their original container to protect from moisture. Linaclotide is intended for long-term use in managing chronic conditions such as IBS-C and , with clinical response typically observed within 1 to 2 weeks of initiation.

Safety profile

Contraindications and precautions

Linaclotide is contraindicated in patients with known or suspected gastrointestinal obstruction, as the drug may exacerbate the obstruction and lead to serious complications. It is also contraindicated in pediatric patients under 2 years of age due to the risk of serious , which has resulted in deaths in nonclinical studies involving young mice administered doses comparable to adult therapeutic levels. Relative precautions apply to certain patient groups where linaclotide may be used but requires careful consideration and monitoring. In children aged 2 to 5 years, the drug should be used with caution due to risks highlighted in the black box warning for young pediatric patients under 2 years, with limited safety data available for this unapproved age group. Linaclotide is approved for in children 6-17 years and IBS-C in 7-17 years as of November 2025, with safety data from clinical trials indicating a profile similar to adults. Elderly patients warrant cautious dosing due to potential increased susceptibility to adverse effects like , although no specific adjustments are needed owing to the drug's negligible systemic absorption; limited data are available in this population. Patients with or a history of bowel should use linaclotide cautiously, as it has not been studied in these populations and its guanylate cyclase-C agonism could potentially worsen gastrointestinal integrity or inflammation. Monitoring is essential to mitigate risks, particularly in vulnerable populations such as children and the elderly. Healthcare providers should regularly assess hydration status and balance, especially during the initial treatment phase or if develops. If severe occurs, linaclotide should be discontinued immediately, and appropriate rehydration measures initiated to prevent and related complications. Linaclotide has negligible systemic absorption and there are no adequate data on the developmental risk in humans. Animal reproduction studies showed no effects on embryo-fetal development except for maternal toxicity in mice at high doses; use during only if the potential benefit justifies the potential risk to the . For , linaclotide and its were not detected in and maternal use is not expected to result in or clinically significant effects.

Adverse effects

The most common adverse effect associated with linaclotide is , reported in approximately 20% of adults with with constipation (IBS-C) and 16% of those with chronic idiopathic constipation () in pooled phase 3 clinical trials. This effect typically begins within the first two weeks of therapy and is dose-dependent, with higher incidence at the 290 mcg daily dose used for IBS-C compared to the 72 mcg or 145 mcg doses for . Severe occurred in about 2% of patients across these trials, often leading to discontinuation in 5% of cases. Other frequently reported adverse effects, occurring in 1-10% of patients, include (7%), (4-6%), (2-3%), (4%), and viral (3%). Less common effects (under 2%) encompass defecation urgency, , , , and upper respiratory tract infections. In pediatric patients aged 6-17 years with functional constipation, diarrhea affected 4%; in those aged 7-17 years with IBS-C, it affected 7-8%, based on clinical studies supporting the 2025 FDA approval. Serious adverse effects are uncommon but include severe , particularly in vulnerable populations such as young children under 2 years, which prompted a black box warning from the FDA due to risks of , , and circulatory compromise. Post-marketing surveillance has identified cases of severe associated with , syncope, , and imbalances requiring hospitalization and intravenous rehydration, though these occur at rates below 1%. Post-marketing reports have also documented hypersensitivity reactions such as , , and , as well as gastrointestinal events including , , and rectal hemorrhage. Elevated liver enzymes have been noted rarely, without clear causality established. Management of adverse effects primarily involves suspending linaclotide dosing during episodes of severe diarrhea and ensuring adequate oral rehydration; dose reduction may be considered upon resolution, though permanent discontinuation is recommended if symptoms persist or recur. Patients are advised to contact their healthcare provider promptly for any signs of or severe symptoms.

Pharmacology

Mechanism of action

Linaclotide acts as a selective of the guanylate cyclase-C (GC-C) receptor, which is expressed on the apical surface of intestinal epithelial cells. This binding mimics the action of endogenous peptides such as guanylin and uroguanylin, as well as the heat-stable enterotoxin produced by , thereby activating the receptor with high potency. Upon receptor activation, linaclotide elevates intracellular and extracellular levels of (cGMP). The increased intracellular cGMP activates protein kinase II (PKG-II), which phosphorylates and opens the (CFTR) chloride channels, promoting the secretion of and ions into the intestinal lumen. Simultaneously, cGMP inhibits sodium absorption by downregulating the sodium-hydrogen exchanger 3 (NHE3) on the apical membrane. These molecular events lead to enhanced fluid secretion into the intestine, which softens stool consistency, accelerates gastrointestinal transit, and facilitates bowel movements. Additionally, the rise in extracellular cGMP in the desensitizes colonic nociceptors, reducing visceral and alleviating abdominal pain associated with conditions like . Linaclotide's design confers specificity for the GC-C receptor, with negligible systemic exposure that confines its pharmacological effects to the . This localized action minimizes off-target effects while maximizing therapeutic benefits in the gut .

Linaclotide exhibits minimal following , resulting in negligible systemic of less than 1%. Plasma concentrations of linaclotide and its remain below the limit of quantitation (0.2 ng/mL for linaclotide and 2.0 ng/mL for the ) after therapeutic doses of 72 mcg, 145 mcg, or 290 mcg. Due to this low , linaclotide primarily acts locally within the intestinal to stimulate guanylate cyclase-C receptors and elevate intracellular (cGMP) levels. Distribution of linaclotide is largely confined to the , with no significant systemic exposure or distribution observed at clinical doses. As levels are not measurable, data are not applicable or clinically relevant. Linaclotide undergoes metabolism primarily in the through proteolytic degradation by enzymes such as carboxypeptidase A, which cleaves the C-terminal residue to form the MM-419447, a 13-amino acid with similar guanylate cyclase-C potency. Both the parent compound and metabolite are further broken down into smaller s and amino acids within the intestinal lumen, with no involvement of enzymes. The of linaclotide in the intestine is approximately 3 minutes for the parent and 10 minutes for MM-419447. Excretion occurs predominantly via the fecal route, with over 95% of the dose degraded locally and eliminated in the as inactive fragments; recovery of intact active (primarily as MM-419447) is low at about 3-5% in after repeated dosing. Urinary is negligible due to the absence of systemic absorption. Administration with does not alter the minimal systemic of linaclotide but may slightly delay its local effects in the intestine without impacting overall efficacy; it is recommended to take linaclotide at least 30 minutes before the first meal of the day to optimize tolerability. No dose adjustments are required for patients with renal or hepatic , as clearance is not affected by these conditions given the drug's localized action and negligible concentrations.

Chemistry

Chemical structure

Linaclotide is a synthetic 14-amino acid peptide with the molecular formula \ce{C59H79N15O21S6}. The primary amino acid sequence of linaclotide is H-Cys¹-Cys²-Glu³-Tyr⁴-Cys⁵-Cys⁶-Asn⁷-Pro⁸-Ala⁹-Cys¹⁰-Thr¹¹-Gly¹²-Cys¹³-Tyr¹⁴-OH, forming a cyclic structure through peptide bonds and stabilized by three intramolecular disulfide bridges. These disulfide bonds connect Cys¹ to Cys⁶, Cys² to Cys¹⁰, and Cys⁵ to Cys¹³, creating a compact, tightly folded conformation with three β-turns that enhances resistance to enzymatic degradation. This structure is a hybrid design derived from the heat-stable enterotoxin STa, incorporating elements that mimic the endogenous peptides guanylin and uroguanylin to facilitate receptor interactions while improving proteolytic stability.

Physical and chemical properties

Linaclotide is an amorphous, white to off-white powder. Its molecular weight is 1526.8 . The compound is slightly soluble in and 0.9% aqueous solution, with exceeding 100 μg/mL in aqueous buffers across a pH range of 1.0 to 7.5. It is sparingly soluble in 0.1 N HCl and very slightly soluble in organic solvents such as acetone and . Linaclotide exhibits stability under acidic conditions throughout the gastrointestinal range, with no significant observed. It is photostable when protected in primary packaging and remains stable for up to 24 months at -20 ± 5°C or 18 months at 5 ± 3°C for bulk material, though the formulated product is stored at controlled (20–25°C; excursions permitted to 15–30°C) in tightly closed containers to protect from moisture. The drug is formulated as oral capsules containing 72 mcg, 145 mcg, or 290 mcg of linaclotide-coated beads within hard shells, which include inactive ingredients such as dihydrate, L-leucine (for higher strengths), (for higher strengths), , and capsule shell components like and .

History

Development and clinical trials

Linaclotide was discovered in by scientists at Microbia Inc., a company that later rebranded as Pharmaceuticals, through efforts aimed at identifying potent guanylate cyclase-C (GC-C) receptor agonists for gastrointestinal disorders. The compound, a 14-amino-acid mimicking the structure of uroguanylin, was selected for its ability to activate GC-C receptors selectively in the . Preclinical studies in animal models, including mice and rats, confirmed linaclotide's efficacy in stimulating and secretion into the intestinal , thereby accelerating gastrointestinal transit and alleviating constipation-like symptoms without detectable systemic absorption or off-target effects. These models also demonstrated antinociceptive properties, reducing visceral in response to colorectal distension, which supported its potential for treating both and components of with constipation (IBS-C). A key milestone in linaclotide's development occurred in September 2007, when Pharmaceuticals entered a 50/50 collaboration with to co-develop and co-commercialize the drug in the United States, providing resources to advance clinical testing. Phase II trials, such as LIN-IBS-301 for IBS-C, established dose-response relationships, showing superior relief of and complete spontaneous bowel movements (CSBMs) compared to , with responder rates exceeding 50% for key endpoints at higher doses. Phase III trials further validated linaclotide's . For , two pivotal studies (LIN-C-301 and LIN-C-302; total n>1,200) demonstrated responder rates of approximately 15-20% for the primary of ≥3 CSBMs per week and an increase of ≥1 CSBM from baseline over 12 weeks for the 145 μg dose, significantly outperforming (3-6%). In IBS-C, pooled data from two pivotal phase III trials (n≈1,600) showed linaclotide 290 μg superior to in co-primary endpoints, with approximately 34% of patients achieving ≥30% reduction in and ≥3 CSBMs weekly for at least 9 of 12 weeks, versus 21% on . Long-term extension studies, up to 18 months in duration, confirmed sustained in CSBM frequency and symptom relief, with consistent responder rates around 40% in open-label cohorts. Pediatric development progressed with phase III trials evaluating linaclotide in children aged 7-17 years with IBS-C or , culminating in 2025 data from a randomized, double-blind study (n=438) that demonstrated and , including improved stool consistency and reduced straining, with no new safety signals beyond those observed in adults. Early development faced challenges with dose-related as the primary , prompting optimizations such as selecting 145 μg for to balance and tolerability while maintaining the 290 μg dose for IBS-C.

Regulatory history

Linaclotide received its initial approval from the U.S. Food and Drug Administration (FDA) on August 30, 2012, for the treatment of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in adults. The European Medicines Agency (EMA) granted marketing authorization for linaclotide, marketed as Constella, on November 26, 2012, for the symptomatic treatment of moderate to severe IBS-C in adults. Subsequent expansions included an FDA label update on June 12, 2023, approving linaclotide for in pediatric patients aged 6 to 17 years at a dose of 72 mcg once daily. On November 5, 2025, the FDA further expanded approval to include IBS-C in pediatric patients aged 7 years and older, at a recommended dose of 145 mcg once daily, marking the first approval for this indication in children. As of 2025, linaclotide is approved in more than 30 countries worldwide, including the , member states, , and . Following the 2014 acquisition of by (later part of ), assumed co-promotion rights in the U.S. under the brand name Linzess; markets it as Constella in ; and Astellas markets it as Linzess in , including . Key labeling updates include the addition of a in 2017 regarding the risk of serious in pediatric patients, based on preclinical studies showing atrophy and death in juvenile mice, leading to in children under 2 years of age. Prior to the 2023 and 2025 pediatric approvals, linaclotide was not indicated for any pediatric use and was generally avoided in children due to these concerns. The FDA has mandated post-approval studies, including long-term evaluations such as open-label extensions and post-marketing surveillance, to monitor ongoing risks like and . No major withdrawals or restrictions have occurred globally.

Society and culture

Brand names and availability

Linaclotide is commercially available under the brand name Linzess in the and . In , , and various other regions including parts of and , it is marketed as Constella. For example, in , markets it under the Linzess brand name. As of November 2025, no generic versions of linaclotide are available in major markets such as the and due to ongoing patent protections, though it became available in in August 2025 under the brand name Colozo by . Ironwood Pharmaceuticals developed linaclotide and retains key rights, while handles marketing in the United States and several international territories, including and . serves as the primary partner for commercialization in , particularly . previously managed European rights but transferred them to in 2015. Linaclotide is available by prescription only and is widely accessible in developed markets such as the , , , and through standard pharmaceutical distribution channels. Its availability remains limited in low-income countries, primarily due to high costs and lack of widespread regulatory approvals or distribution networks, though the August 2025 launch in represents an expansion into emerging markets. In the , exclusivity for linaclotide extends until at least 2029 for certain dosages following agreements with generic manufacturers, with potential pediatric extensions that could delay generic entry further; the 72 mcg formulation has patents expiring in 2026. In the , European Medicines Agency-related patents are set to expire in 2026. To improve access, Pharmaceuticals and offer patient assistance programs , providing free or discounted medication to eligible uninsured or underinsured patients. These programs include the LINZESS Savings Card, which can reduce out-of-pocket costs for commercially insured individuals.

Economics

Linaclotide's global market size reached USD 1.425 billion in 2024, driven by increasing demand for treatments for with constipation (IBS-C) and idiopathic constipation (CIC). Projections indicate continued growth at a (CAGR) of approximately 6.8% from 2025 onward, potentially reaching USD 2.5 billion by 2033, with recent pediatric approvals for IBS-C expected to expand the patient population and further boost sales. In the United States, the retail price for a 30-day supply of linaclotide (290 mcg capsules) is approximately USD 568 as of early 2025, though costs without can exceed USD 750 per month. Generic versions remain unavailable, as the primary U.S. protection extends until 2026, delaying market entry. Pricing in is generally lower than in the U.S., reflecting regional and market dynamics, though specific figures vary by country. Prescription trends in the U.S. show approximately 2.8 million prescriptions for linaclotide in , ranking it 178th among dispensed medications. Uptake has been supported by campaigns launched around , which aimed to raise awareness of IBS-C and CIC symptoms. Cost-effectiveness analyses demonstrate that linaclotide offers favorable incremental cost-effectiveness ratios (ICERs) compared to or alternative therapies for IBS-C and , with studies in regions like and showing gains in quality-adjusted life years (QALYs) at acceptable cost thresholds. However, without coverage, the high out-of-pocket burden—often over USD 700 monthly—limits for some patients. Ironwood Pharmaceuticals, the developer of linaclotide, reported net collaboration revenue of approximately USD 431 million in 2023 from U.S. sales of the drug (marketed as Linzess), primarily through its profit-sharing partnership with . Additional royalties stem from international partnerships, such as with Astellas in and China, contributing to overall revenue streams.

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