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Damian returns to see you a few weeks later. He says he has maintained the lifestyle changes you discussed and he continues to be more active. However his bowel movements remain unchanged despite taking regular, full dose macrogol laxatives. You prescribe a full dose trial of ispaghula husk.Three weeks later, Damian returns to see you: he has seen no benefit. Another full dose trial, this time of senna, does not improve his symptoms either. His symptoms have been troublesome for well over a year, he has been taking treatment for 6 months, and it is clear that he is feeling dispirited by it all.What should you do next?Consider prescribing linaclotideRefer Damian to a specialist gastroenterologistRefer Damian for CBTTell Damian that there is nothing more that can be doneSubmit

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