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Koo H, Jeong KH, Jeon N, Jung SY. Factors associated with the use of traditional doses of amitriptyline for chronic pain management: A cross-sectional study. Medicine (Baltimore) 2024; 103:e36790. [PMID: 38181253 PMCID: PMC10766233 DOI: 10.1097/md.0000000000036790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 12/05/2023] [Indexed: 01/07/2024] Open
Abstract
There are studies on the effect of low-dose amitriptyline on pain control, but there is a lack of studies on the use of amitriptyline for chronic pain and the factors associated with the prescription of traditional doses. We used a national sample cohort of patients aged ≥ 18 years who were prescribed amitriptyline along with chronic pain, without psychiatric disorders, between 2002 to 2015. We categorized the prescriptions into 2 groups according to the daily dose: low doses (≤25 mg) and traditional doses (>25 mg). Multivariable logistic regression models were used to identify factors associated with traditional dose prescriptions. Among 177,769 prescriptions for amitriptyline, 15,119 (8.5%) were prescribed for chronic pain. The prevalence of prescriptions and proportion of traditional doses of amitriptyline tended to decrease during the study period. Male sex (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.13); age 65-80 years (OR 1.12, 95% CI 1.08-1.16), especially ≥ 80 years (OR 1.55, 95% CI 1.45-1.65); headaches (OR 1.18, 95% CI 1.10-1.27), receiving medical aids (OR 2.58, 95% CI 2.46-2.71); and being prescribed benzodiazepines or zolpidem concomitantly (OR 1.10, 95% CI 1.06-1.15) were significantly associated with traditional dose prescriptions of amitriptyline. Although traditional dose prescriptions of amitriptyline have been declining, close monitoring is still required in the presence of the above-mentioned factors.
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Affiliation(s)
- Hyunji Koo
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | | | - Nakyung Jeon
- College of Pharmacy, Pusan National University, Pusan, Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Korea
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, Chung-Ang University, Seoul, Korea
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Mascarenhas A, Mendo R, O'Neill C, Franco AR, Mendes R, Simão I, Rodrigues JP. Current Approach to Dysphagia: A Review Focusing on Esophageal Motility Disorders and Their Treatment. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:403-413. [PMID: 38476159 PMCID: PMC10928869 DOI: 10.1159/000529428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/13/2023] [Indexed: 03/14/2024]
Abstract
Background Dysphagia is a prevalent condition which may severely impact the patient's quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders. Summary Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients' illness experience and help providers better understand symptoms from the patients' perspective. Therefore, PROs have a critical role in providing patient-centered care. Key Messages Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.
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Affiliation(s)
- André Mascarenhas
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Rui Mendo
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Catarina O'Neill
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Ana Rita Franco
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Raquel Mendes
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Inês Simão
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - José Pedro Rodrigues
- Gastroenterology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
- Pathophysiology Autonomous Disciplinary Area, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Risk of cardiovascular events according to the tricyclic antidepressant dosage in patients with chronic pain: a retrospective cohort study. Eur J Clin Pharmacol 2023; 79:159-171. [PMID: 36443528 DOI: 10.1007/s00228-022-03421-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/07/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to examine the risk of cardiovascular adverse events by tricyclic antidepressant (TCA) dosage among patients with chronic pain. METHODS A retrospective cohort study was conducted using a nationwide sample cohort. Among patients aged ≥ 18 years with a chronic pain diagnosis and no history of cardiovascular events, we extracted users and non-users of TCAs through 1:1 propensity score matching. TCA users were categorized into three groups according to the mean defined daily dose (DDD): very low doses (< 0.15 DDD), low doses (0.15-0.34 DDD), and traditional doses (≥ 0.34 DDD). A 6-month follow-up was conducted with an intention-to-treat approach. We examined the hazard ratio of cardiovascular adverse events using Cox proportional hazards analysis. RESULTS In total, 16,660 matched patients were followed up (8330 TCA users and 8330 non-users). TCA use did not significantly increase cardiovascular adverse events (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.94-1.33). Low-dose (0.15-0.34 DDD) TCAs (HR 1.37, 95% CI 1.08-1.74), particularly low-dose (0.15-0.34 DDD) nortriptyline (HR 2.11, 95% CI 1.44-3.08), was associated with an increased risk of cardiovascular adverse events. Administration of TCAs at the traditional dose (≥ 0.34 DDD) increased the risk of ischemic stroke (HR 2.08, 95% CI 1.11-3.88). CONCLUSION Close monitoring of patients on long-term, low-dose use of TCAs should be conducted to avoid an increase in the cumulative dose, which increases the risk of cardiovascular adverse events.
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Huang Q, Zheng S, Cai T, Zhang S, Su Q, Wang F. Factors associated with mood disorders and the efficacy of the targeted treatment of functional dyspepsia: A randomized clinical trial. Front Med (Lausanne) 2022; 9:859661. [PMID: 35935797 PMCID: PMC9353185 DOI: 10.3389/fmed.2022.859661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients with functional dyspepsia (FD) are often accompanied by mood disorders (MDs). This study aimed to identify factors associated with MDs in patients with FD and evaluate the efficacy of targeted treatment plans.MethodsRelevant scales were used to assess MDs. Patients with FD having MDs and acid reflux were treated with flupentixol and melitracen (FM) and acid-suppressive therapy (AST) (histamine-2 receptor antagonists (H2RAs) (group A) or proton pump inhibitors (PPIs) (group B)), and those without acid reflux (group C) did not receive AST. Patients with FD without MDs were randomly administered H2RAs (group D) or PPIs (group E). The primary endpoints were factors associated with MDs and improvement in gastrointestinal (GI) symptoms and MDs in patients with FD.ResultsA total of 362 patients with FD were enrolled in this study. Patients with FD having high GI score and low education were found prone to MDs. At week 2, the remission rate of overall GI symptoms and depression was significantly higher in group B than that in groups A and C [GI: 72.72% (32/44) vs. 47.73% (21/44) and 72.72% (32/44) vs. 38.94% (44/113), all P < 0.05; depression: 72.22% (26/36) vs. 41.67% (15/36) and 72.22% (26/36) vs. 41.57% (37/89), all P < 0.05]. Furthermore, the remission rate of overall GI symptoms was significantly higher in group E than that in group D [60.29% (41/68) vs. 42.65% (29/68), P < 0.05]. At week 8, similar efficacies and adverse reactions were observed in these groups.ConclusionThe risk factors for MDs were high GI scores and low literacy rates. Thus, targeted treatment (FM+PPIs for patients with MDs; PPIs for patients without MDs) can improve the efficacy of patients with FD.Clinical trial registrationwww.chictr.org.cn, identifier ChiCTR2100053126.
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Affiliation(s)
- Qian Huang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
| | - Shaopeng Zheng
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
| | - Ting Cai
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
| | - Suxin Zhang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
| | - Qian Su
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
| | - Fen Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Non Resolving Inflammation and Cancer, Changsha, China
- *Correspondence: Fen Wang
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Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
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Bhardwaj R, Knotts R, Khan A. Functional Chest Pain and Esophageal Hypersensitivity: A Clinical Approach. Gastroenterol Clin North Am 2021; 50:843-857. [PMID: 34717874 DOI: 10.1016/j.gtc.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Functional chest pain, functional heartburn, and reflux hypersensitivity are 3 functional esophageal disorders defined by the Rome IV criteria. Specific criteria, combining symptoms and the results of objective testing, allow for an accurate diagnosis of these conditions. Management may include medications targeted at optimizing acid suppression or neuromodulation, as well as a host of complementary or alternative treatment options. Psychological and behavioral interventions, such as cognitive behavioral therapy and hypnotherapy, have displayed substantial benefits in the treatment of functional chest pain and functional heartburn. Acid suppression and focused neuromodulation are key evidence-based treatment options for reflux hypersensitivity.
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Affiliation(s)
- Richa Bhardwaj
- Department of Internal Medicine, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075, USA
| | - Rita Knotts
- Department of Medicine, NYU Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA
| | - Abraham Khan
- Department of Medicine, NYU Langone Health, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
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Patel D, Fass R, Vaezi M. Untangling Nonerosive Reflux Disease From Functional Heartburn. Clin Gastroenterol Hepatol 2021; 19:1314-1326. [PMID: 32246998 DOI: 10.1016/j.cgh.2020.03.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 02/07/2023]
Abstract
Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.
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Affiliation(s)
- Dhyanesh Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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8
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Abstract
PURPOSE OF REVIEW This paper aims to review the definition and diagnostic criteria for reflux hypersensitivity and comment on the present and future management of this condition. RECENT FINDINGS In 2016, the Rome IV criteria redefined reflux hypersensitivity as characterized by typical reflux symptoms, absence of endoscopic mucosal disease, absence of pathologic gastroesophageal reflux, and positive symptom correlation between reflux and heartburn episodes. Though uncertain, TPRV1 receptors have been implicated in the pathophysiology of reflux hypersensitivity. Recent studies have shown neuromodulators like SSRIs, SNRIs, and TCAs may be the future of managing this condition. With the release of the Rome IV criteria and availability of continuous pH monitoring, the diagnosis of reflux hypersensitivity has become more streamlined. Though there is no definitive therapy for reflux hypersensitivity, several anti-secretory agents and neuromodulators have shown some efficacy in therapeutic trials. The lack of large-scale, randomized controlled trials, however, reinforces the need for further research into the pharmacotherapy of reflux hypersensitivity.
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Affiliation(s)
- Pankaj Aggarwal
- University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Afrin N Kamal
- Division of Gastroenterology, Stanford University, 420 Broadway Street, Pavilion D, Redwood City, CA, 94063, USA.
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9
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Fass R, Shibli F, Tawil J. Diagnosis and Management of Functional Chest Pain in the Rome IV Era. J Neurogastroenterol Motil 2019; 25:487-498. [PMID: 31587539 PMCID: PMC6786446 DOI: 10.5056/jnm19146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 12/13/2022] Open
Abstract
Functional chest pain accounts for about a third of the patients with noncardiac chest pain. It is a very common functional esophageal disorder that remains even today a management challenge to the practicing physician. Based on the definition offered by the Rome IV criteria, diagnosis of functional chest pain requires a negative workup of noncardiac chest pain patients that includes, proton pump inhibitor test or empirical proton pump inhibitor trial, endoscopy with esophageal mucosal biopsies, reflux testing, and esophageal manometry. The mainstay of treatment are neuromodulators that are primarily composed of anti-depressants. Alternative medicine and psychological interventions may be provided alone or in combination with other therapeutic modalities.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Fahmi Shibli
- The Esophageal and Swallowing Center, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jose Tawil
- Departamento de Trastornos Funcionales Digestivos, Gedyt-Gastroenterología Diagnóstica y Terapéutica, BuenosAires, Argentina
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez R, Remes-Troche J, Abreu-Abreu A, Cerda-Contreras E, Gómez-Castaños P, González-Martínez M, Huerta-Iga F, Ibarra-Palomino J, Icaza-Chávez M, López-Colombo A, Márquez-Murillo M, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez J, Torres-Barrera G, Valdovinos-García L, Valdovinos-Díaz M, Vázquez-Elizondo G, Villar-Chávez A, Zavala-Solares M, Achem S. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez RI, Remes-Troche JM, Abreu Y Abreu AT, Cerda-Contreras E, Gómez-Castaños PC, González-Martínez MA, Huerta-Iga FM, Ibarra-Palomino J, Icaza-Chávez ME, López-Colombo A, Márquez-Murillo MF, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez JL, Torres-Barrera G, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Zavala-Solares M, Achem SR. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:372-397. [PMID: 31213326 DOI: 10.1016/j.rgmx.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/22/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles Puebla, Puebla, Puebla, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A T Abreu Y Abreu
- Gastroenterología y Fisiología Digestiva, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - E Cerda-Contreras
- Medicina Interna, Gastroenterología y Motilidad Gastrointestinal, Hospital Médica Sur, Profesor de Medicina ITESM, Ciudad de México, México
| | | | - M A González-Martínez
- Departamento de Endoscopia, Laboratorio de Motilidad Gastrointestinal, Hospital de Especialidades CMN Siglo XXI IMSS, Ciudad de México, México
| | - F M Huerta-Iga
- Jefe de Endoscopia y Fisiología Digestiva, Hospital Ángeles Torreón, Torreón, Coahuila, México
| | - J Ibarra-Palomino
- Laboratorio de Motilidad Gastrointestinal, Área de Gastroenterología, Hospital Ángeles del Carmen, Guadalajara, Jalisco, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Profesora de Gastroenterología de la UNIMAYAB, Mérida, Yucatán, México
| | - A López-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional «Manuel Ávila Camacho», Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - M F Márquez-Murillo
- Cardiólogo Electrofisiólogo, Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - M Mejía-Rivas
- Gastroenterología, Endoscopia, Neurogastroenterología, Hospital «Vivien Pellas», Managua, Nicaragua
| | | | - J L Rodríguez-Chávez
- Gastroenterología y Neurogastroenterología, Hospital Puerta de Hierro, Guadalajara, Jalisco, México
| | - G Torres-Barrera
- Departamento de Gastroenterología, Hospital Universitario, Universidad Autónoma de Nuevo León, Profesor de cátedra, ITESM, Monterrey, Nuevo León, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, OnCare Group, Monterrey, Nuevo León, México
| | - A S Villar-Chávez
- Gastroenterología y Motilidad Gastrointestinal, Hospital Ángeles Acoxpa, Ciudad de México, México
| | - M Zavala-Solares
- Unidad de Motilidad Gastrointestinal, Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - S R Achem
- Profesor de Medicina Interna y Gastroenterología, Facultad de Medicina, Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida, Estados Unidos de América
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Oesophageal dysphagia: a stepwise approach to diagnosis and management. Lancet Gastroenterol Hepatol 2018; 2:604-609. [PMID: 28691686 DOI: 10.1016/s2468-1253(17)30001-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/20/2016] [Accepted: 01/03/2017] [Indexed: 12/19/2022]
Abstract
Dysphagia is a common symptom in the general population. Incidence varies depending on the specific definition used. A good medical history is vital for distinguishing true oesophageal dysphagia from oropharyngeal dysphagia or other causes. Oesophageal dysphagia is a so-called red flag alarm symptom requiring oesophagogastroduodenoscopy. However, even after investigations including oesophagogastroduodenoscopy (with biopsy), barium swallow, and oesophageal manometry, no obstructive cause may be found. This Review suggests an algorithm of history-taking and investigation to allow the causes of non-obstructive dysphagia to be identified, including functional dysphagia. The Review then discusses management strategies and outcomes for functional dysphagia.
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Gyawali CP, Fass R. Management of Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:302-318. [PMID: 28827081 DOI: 10.1053/j.gastro.2017.07.049] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/29/2017] [Accepted: 07/31/2017] [Indexed: 02/06/2023]
Abstract
Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio.
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Faruqui AA. Gastroesophageal Reflux Disease Associated With Anxiety: Efficacy and Safety of Fixed Dose Combination of Amitriptyline and Pantoprazole. Gastroenterology Res 2017; 10:301-304. [PMID: 29118871 PMCID: PMC5667696 DOI: 10.14740/gr898e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 01/24/2023] Open
Abstract
Background The aim of the study was to evaluate the efficacy and tolerability of fixed dose combination of amitriptyline and pantoprazole in gastroesophageal reflux disease (GERD) associated with anxiety. Methods A non-randomized, open-labeled, non-comparative, multi-center study was conducted in a total of 99 patients (77 men and 22 women, mean age 44.16 ± 11.53 years). Each patient was administered a fixed dose combination of amitriptyline 10 mg and pantoprazole 40 mg once a day, for 4 weeks. GERD questionnaire, hospital anxiety and depression score (HADS) and SF-8 questionnaire (short-form health survey) were performed at baseline and at the end of study as assessment tools. Results At the end of study, data were extractable only in 96 patients because three patients were dropped out due to loss of follow-up at week 4. GERD symptoms and anxiety score reduced significantly (P < 0.0001) at week 4 compared to baseline. SF-8 score also improved significantly (P < 0.0001) at week 4. There were no adverse events reported. Conclusion Amitriptyline and pantoprazole combination was found to be effective and safe for management in GERD patients with coexisting anxiety.
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Affiliation(s)
- Arif A Faruqui
- Department of Pharmacology, A 504, Rizvi Mahal, Opp. K.B. Bhabha Hospital, Waterfield Road, Bandra West 400050, India.
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Hoff DAL, Brock C, Farmer AD, Dickman R, Ruffle JK, Shaker A, Drewes AM. Pharmacological and other treatment modalities for esophageal pain. Ann N Y Acad Sci 2016; 1380:58-66. [PMID: 27442914 DOI: 10.1111/nyas.13151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/23/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Treatment of esophageal pain remains a major challenge for the clinician. Although many patients have heartburn and may respond to proton pump inhibitors, there in an unmet need for other treatment modalities in patients where there are no obvious pathological findings. Although analgesics are the mainstay in esophageal pain treatment, many patients are nonresponders to these drugs. The current concise review focuses on other systems affecting pain processing, where better understanding may serve as a framework for therapy. These are the parasympathetic nervous system, exercise, and personality profiles. Finally, treatment with analgesics for functional chest pain remains a challenge, and an overview of treatment with antidepressive drugs is provided.
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Affiliation(s)
- Dag Arne Lihaug Hoff
- Clinic of Medicine HMR Hospital Trust, Department of Medicine, Division of Gastroenterology & Hepatology, Aalesund Hospital, Aalesund, Norway.
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Adam D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, United Kingdom
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Campus, Petach Tikva & Sackler School of Medicine, University of Tel Aviv, Israel
| | - James K Ruffle
- Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - Anisa Shaker
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital and Clinical Institute, Aalborg University, Aalborg, Denmark
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George N, Abdallah J, Maradey-Romero C, Gerson L, Fass R. Review article: the current treatment of non-cardiac chest pain. Aliment Pharmacol Ther 2016; 43:213-39. [PMID: 26592490 DOI: 10.1111/apt.13458] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/02/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed. AIM To determine the value of the current therapeutic modalities for NCCP. METHODS Electronic (Pubmed/Medline/Cochrane central) and manual search. RESULTS Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients. CONCLUSION Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.
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Affiliation(s)
- N George
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - J Abdallah
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - C Maradey-Romero
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - L Gerson
- Division of Gastroenterology, California Pacific Medical Center, University of California, San Francisco, San Francisco, CA, USA
| | - R Fass
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Functional oesophageal disorders must be diagnosed properly and treated accordingly. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0182-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
After excluding a cardiac cause, potent anti-reflux therapy should be administered to patients with non-cardiac chest pain since gastroesophageal reflux disease (GERD) is the most common underlying mechanism of this disorder. If GERD is an unlikely cause of patient's symptoms, an esophageal motor disorder should be excluded. Spastic motility disorders can be treated with a smooth muscle relaxant (such as calcium channel blocker, nitrate, or phosphodiesterase 5 inhibitors). Alternatively, spastic motility disorders may respond to anti-spasmodics, pain modulators, botulinum toxin injection into the distal esophagus, and/or surgery. Patients with functional chest pain have recently seen an expanded treatment armamentarium including medications such as trazadone, tricyclic anti-depressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, pregabalin, and/or ramelteon.
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Affiliation(s)
- Carla Maradey-Romero
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109-1998, USA
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Maradey-Romero C, Gabbard S, Fass R. Treatment of esophageal motility disorders based on the chicago classification. ACTA ACUST UNITED AC 2014; 12:441-55. [PMID: 25263532 DOI: 10.1007/s11938-014-0032-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.
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Affiliation(s)
- Carla Maradey-Romero
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109 -1998, USA
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Blackshaw LA, Bordin DS, Brock C, Brokjaer A, Drewes AM, Farmer AD, Krarup AL, Lottrup C, Masharova AA, Moawad FJ, Olesen AE. Pharmacologic treatments for esophageal disorders. Ann N Y Acad Sci 2014; 1325:23-39. [DOI: 10.1111/nyas.12520] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- L. Ashley Blackshaw
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology; Barts and the London School of Medicine & Dentistry, Queen Mary University of London; London United Kingdom
| | - Dmitry S. Bordin
- Central Research Institute of Gastroenterology; Moscow Russian Federation
| | - Christina Brock
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
| | - Anne Brokjaer
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
| | - Asbjørn Mohr Drewes
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
| | - Adam D. Farmer
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Wingate Institute of Neurogastroenterology; Barts and the London School of Medicine & Dentistry, Queen Mary University of London; London United Kingdom
| | - Anne Lund Krarup
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
| | - Christian Lottrup
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
| | | | - Fouad J. Moawad
- Department of Medicine; Walter Reed National Military Medical Center; Bethesda Maryland
| | - Anne Estrup Olesen
- Department of Medical Gastroenterology; Aalborg University Hospital; Aalborg Denmark
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Dickman R, Maradey-Romero C, Fass R. The role of pain modulators in esophageal disorders - no pain no gain. Neurogastroenterol Motil 2014; 26:603-10. [PMID: 24750261 DOI: 10.1111/nmo.12339] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 03/11/2014] [Indexed: 01/25/2023]
Abstract
Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade.
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Affiliation(s)
- R Dickman
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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