Tricyclic antidepressants for management of residual symptoms in inflammatory bowel disease

Abstract

Background: Tricyclic antidepressants (TCAs) have efficacy in treating irritable bowel syndrome (IBS). Some clinicians use TCAs to treat residual symptoms in inflammatory bowel disease (IBD) patients already on decisive IBD therapy or with quiescent inflammation, although this strategy has not been formally studied.

Goals: The aim of this study was to examine the efficacy of TCA therapy in IBD patients with residual symptoms, despite controlled inflammation, in a retrospective cohort study.

Study: Inclusion required initiation of TCA for persistent gastrointestinal symptoms. IBD patients had inactive or mildly active disease with persistent symptoms despite adequate IBD therapy as determined by their physician. Symptom response was compared with IBS patients. Established Likert scales were used to score baseline symptom severity (0=no symptoms, 3=severe symptoms) and TCA response (0=no improvement; 3=complete satisfaction).

Results: Eighty-one IBD [41.3±1.7 y, 56F; 58 Crohn's disease/23 ulcerative colitis (UC)] and 77 IBS (46.2±1.7 y, 60F) patients were initiated on a TCA therapy. Baseline symptom scores (IBD, 2.06±0.03; IBS, 2.12±0.04; P=0.15) and symptom response to TCA therapy (IBD, 1.46±0.09; IBS, 1.30±0.09; P=0.2) were similar in both the groups. At least moderate improvement (Likert score ≥2) on TCA was achieved by comparable proportions of patients (59.3% IBD vs. 46% IBS; P=0.09). Within IBD, response was better with UC than Crohn's disease (1.86±0.13 vs. 1.26±0.11, respectively, P=0.003).

Conclusions: In a clinical practice setting, TCA use led to moderate improvement of residual gastrointestinal symptoms in IBD patients for whom escalation of IBD therapy was not planned. UC patients demonstrated higher therapeutic success. IBD symptom responses were similar to IBS patients.

Figure 1

Likert scale used for extracting baseline symptom severity and treatment outcome from chart review. The scoring system has documented reproducibility and high interobserver agreement (κ = 0.86-0.89). In the outcome scale, scores of 2 or 3 represented treatment response. Reproduced with permission from Schirbel et al. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

Figure 2

Baseline and symptom response Likert scores on 81 IBD and 77 IBS patients at baseline and first follow-up. *Higher baseline symptom scores indicate more severe symptoms. **Higher follow-up symptom response scores indicate better symptom improvement. Second follow-up symptom response (54 IBD and 60 IBS patients) represents further symptom improvement over the first follow-up. IBD indicates inflammatory bowel disease, IBS, irritable bowel syndrome.

Figure 3

Proportion of IBD and IBS patients with at least moderate improvement on TCA therapy [≥ 2 on Likert scale (Fig. 1)]. *P = 0.09 between IBD and IBS at first follow-up; n = 81 IBD, 77 IBS. **P = 0.29 between IBD and IBS at second follow-up; n = 54 IBD, 60 IBS. IBD indicates inflammatory bowel disease, IBS, irritable bowel syndrome.