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Psyllium (Plantago ovata, ispaghula husk)

Soluble and insoluble fibre from seed husk. AEMPS registered Plantaben and Cenat as medicinal products for chronic constipation and maintenance of normal defecation. ACG 2014 and NICE NG61 IBS 2017 list psyllium as the primary soluble fibre

ATC code: A06AC-PSYLLIUM

Brand names – supplements: Konsyl Psyllium Husk, Now Psyllium Husk Powder, Metamucil, FybogelSupplements are not tested in clinical trials and are not registered as medications.

Updated · Methodology

Indications

A

Chronic constipation

First line

Psyllium is the first-line soluble fibre in chronic functional constipation per 2014 monograph and recommendations. AEMPS registered Plantaben and Cenat with the indication of functional constipation and maintenance of normal defecation. Christodoulides 2016 meta-analysis (7 RCTs, 405 patients) showed increased stool frequency and improved consistency on psyllium 10–20 g/day × 4 weeks. 2013 approved a health claim for psyllium on increased stool bulk at minimum 7 g/day. ACG 2014 in chronic constipation lists first-line: soluble psyllium fibre 7–10 g/day with ample water, osmotic laxatives (PEG/macrogol) if insufficient, stimulant laxatives (bisacodyl, sennosides) for persistent constipation, novel drugs (linaclotide, prucalopride, lubiprostone) for refractory constipation. Dose: start at 3.5 g 1–2 times daily, gradually increase to 7–10 g/day with minimum 250 mL of water per dose.

Sources

  1. ACG: American College of Gastroenterology monograph on the management of chronic constipation (2014)
  2. EFSA: Scientific Opinion on the substantiation of a health claim related to ispaghula (Plantago ovata Forsk.) seed coat and an increase in faecal bulk (2013)
  3. EMA HMPC: Community herbal monograph on Plantago ovata Forssk., seminis tegumentum (2013)
  4. AEMPS / CIMA: Plantaben 3,5 g granulado efervescente (Plantago ovata) – ficha técnica (2024)
  5. AEMPS / CIMA: Cenat 3,5 g granulado efervescente (Plantago ovata) – ficha técnica (2024)

ICD-10: K59.0 · ICD-11: ME05.0

B

Irritable bowel syndrome

Adjunct

Psyllium is one of the few soluble fibres with evidence in irritable bowel syndrome, especially IBS-C. Moayyedi 2014 meta-analysis (14 RCTs, 906 patients) showed moderate global IBS symptom improvement with soluble fibre (psyllium, ispaghula), but not insoluble (wheat bran). NG61 IBS 2017 in IBS-C and mixed forms lists soluble psyllium fibre with gradual dose increase first-line. 2021 IBS guideline gives a strong recommendation for soluble fibre use (psyllium, ispaghula). Evidence base is stronger than for probiotics. In IBS-D, psyllium may worsen bloating in some patients – individual dose titration required. Effect develops over 2–4 weeks of use.

Sources

  1. Cochrane / AGA: The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis (2014)
  2. Am J Gastroenterol: Efficacy of soluble fibre, antispasmodic agents, and peppermint oil in IBS: systematic review and meta-analysis (2014)
  3. NICE: Irritable bowel syndrome in adults: diagnosis and management (CG61) (2017)
  4. ACG: ACG clinical guideline: management of irritable bowel syndrome (2021)

ICD-10: K58.8 · ICD-11: DD91.0Z

B

Primary hypercholesterolemia

Adjunct

Psyllium is one of the few dietary supplements with confirmed cardiometabolic benefit. 2010 approved the health claim: «psyllium husk contributes to maintenance of normal blood cholesterol» at minimum 7 g/day. Brown 1999 meta-analysis (8 RCTs) and updated Wei 2009 showed 5–10% reduction on psyllium 7–10 g/day × 8 weeks. in the US allowed a heart-health claim for psyllium from 1998. in hypercholesterolaemia list statins (atorvastatin, rosuvastatin) first-line; statin intolerance or insufficient effect – ezetimibe, PCSK9 inhibitors (alirocumab, evolocumab), bempedoic acid. Psyllium may be used as adjunct to statin for additional 5–10% LDL reduction but does not replace statin in high cardiovascular risk patients. If psyllium was recommended as a statin substitute in coronary disease, prior myocardial infarction or stroke, consider seeking a second opinion from a cardiologist.

Sources

  1. EFSA NDA Panel: Scientific Opinion on the substantiation of health claims related to Vaccinium myrtillus (bilberry) (2010)
  2. EMA HMPC: Community herbal monograph on Plantago ovata Forssk., seminis tegumentum (2013)

ICD-10: E78.0 · ICD-11: 5C80.00

Marketing claims without evidence base

The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.

D

Type 2 diabetes mellitus

Not recommended

Psyllium is offered in type 2 diabetes as a «natural sugar control». Gibb 2015 meta-analysis (35 RCTs, 1377 patients) showed moderate reduction (by 0.4–0.6%) and postprandial glycaemia on psyllium 10–20 g/day × 12 weeks. Effect is modest, not comparable to glucose-lowering pharmacotherapy. Standards of Care 2024 in T2DM list metformin + lifestyle modification first-line; if HbA1c >7.5% or comorbid CVD, kidney disease, obesity – GLP-1 agonists (semaglutide, dulaglutide) or SGLT-2 inhibitors. Psyllium may be used as adjunct for moderate additional HbA1c reduction in patients with hypercholesterolaemia and T2DM but not as substitute for metformin or GLP-1 agonist. If psyllium was recommended as a substitute for standard glucose-lowering therapy, consider seeking a second opinion from an endocrinologist.

Sources

  1. EFSA NDA Panel: Scientific Opinion on the substantiation of health claims related to Vaccinium myrtillus (bilberry) (2010)

ICD-10: E11 · ICD-11: 5A11

How to read tiers A–F
  • AStrong evidence – first or second line in international guidelines
  • BRecommended in selected cases
  • CStudy data contradict each other
  • DBenefit not proven, no documented harm
  • FDocumented harm, or risk without benefit

Mechanism of action

Psyllium is the seed husk of Plantago ovata, containing up to 70% soluble fibre (arabinoxylans) and 30% insoluble. It swells in water forming a viscous gel that increases intestinal content volume, softens stool and eases evacuation. The soluble fraction binds bile acids in the intestine, increasing their faecal excretion; the liver compensates this loss by synthesising new ones from endogenous cholesterol, reducing by 5–10% at 7–10 g/day × 8 weeks. Gel formation slows glucose absorption and reduces postprandial glycaemia. approved two health claims: for psyllium husk on maintenance of normal blood cholesterol (2010) and on increased stool bulk (2013). HMPC 2013 recognised psyllium as a well-established use medicinal product for functional constipation and IBS.

Safety

Contraindications

  • Intestinal obstruction or suspected obstruction
  • Oesophageal or intestinal stenosis
  • Intestinal atony
  • Diabetes with insulin adaptation problems to slowed carbohydrate absorption (requires insulin dose adjustment)
  • Established hypersensitivity to Plantago ovata
  • Narrow therapeutic index drugs (lithium, warfarin, digoxin, levothyroxine, carbamazepine) – psyllium may reduce their absorption; space doses by 1–2 hours

Serious adverse effects

  • Intestinal obstruction with insufficient fluid intake (psyllium bezoar)
  • Aspiration when taken without water in elderly and dysphagia patients
  • Anaphylaxis (very rare)
  • Reduced efficacy of narrow therapeutic index drugs when co-administered

Common adverse effects

  • Abdominal bloating, flatulence (first 1–2 weeks of use)
  • Epigastric fullness
  • Stool pattern change
  • Allergic reactions to seed dust (rhinovirus-like symptoms, bronchospasm – in pharmaceutical production workers)

Pregnancy: can you take Psyllium (Plantago ovata, ispaghula husk)?

In pregnancy, psyllium is permitted and considered one of the preferred options for gestational constipation. AEMPS Plantaben and Cenat SmPCs: use in pregnancy permitted when clearly needed. Not absorbed from GI tract; no systemic foetal effect.

Breastfeeding: can you take Psyllium (Plantago ovata, ispaghula husk)?

Compatible with breastfeeding. Not absorbed into systemic circulation; does not transfer to milk.

Calculate RID

Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.

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Frequently asked

What is Psyllium (Plantago ovata, ispaghula husk) used for?

Psyllium (Plantago ovata, ispaghula husk) is evaluated for the following indications with varying evidence strength: Chronic constipation (evidence tier A), Irritable bowel syndrome (evidence tier B), Primary hypercholesterolemia (evidence tier B). See the full indication matrix with dosing and citations above on this page.

What are the side effects of Psyllium (Plantago ovata, ispaghula husk)?

Common side effects of Psyllium (Plantago ovata, ispaghula husk) (≥ 1 in 100): Abdominal bloating, flatulence (first 1–2 weeks of use), Epigastric fullness, Stool pattern change, Allergic reactions to seed dust (rhinovirus-like symptoms, bronchospasm – in pharmaceutical production workers). See the Safety section for uncommon and serious reactions.

Is Psyllium (Plantago ovata, ispaghula husk) safe during pregnancy?

In pregnancy, psyllium is permitted and considered one of the preferred options for gestational constipation. AEMPS Plantaben and Cenat SmPCs: use in pregnancy permitted when clearly needed. Not absorbed from GI tract; no systemic foetal effect.

Is Psyllium (Plantago ovata, ispaghula husk) compatible with breastfeeding?

Compatible with breastfeeding. Not absorbed into systemic circulation; does not transfer to milk.

Who should not take Psyllium (Plantago ovata, ispaghula husk)?

Psyllium (Plantago ovata, ispaghula husk) is contraindicated in: Intestinal obstruction or suspected obstruction; Oesophageal or intestinal stenosis; Intestinal atony; Diabetes with insulin adaptation problems to slowed carbohydrate absorption (requires insulin dose adjustment); Established hypersensitivity to Plantago ovata. Full list in the Safety section.

Other drugs in this group

Bisacodyl, Glycerol, Inulin (chicory/agave/Jerusalem artichoke prebiotic), Sodium lauryl sulfoacetate, Sodium picosulfate