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.
Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium.
Gastroenterology. 2018 Mar;154(4):1140-1171.e1. doi: 10.1053/j.gastro.2017.11.279. Epub 2017 Dec 22.
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.
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.
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.
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.
中枢神经调节剂（抗抑郁药、抗精神病药和其他针对中枢神经系统的药物）越来越多地用于治疗功能性胃肠疾病（FGIDs），这些疾病现在被认为是肠-脑相互作用障碍。然而，关于这些疾病中使用中枢神经调节剂的现有证据和指导意见很少且不完整。在这份罗马基金会工作组报告中，一个多学科小组总结了现有的研究证据和临床经验，提供了指导和治疗建议。
工作组总结了中枢神经调节剂的药理学及其对胃肠道感觉运动功能影响的文献，并对其用于治疗 FGID 综合征的作用进行了基于证据的综述。由于 FGIDs 的数据很少，我们还包括了非胃肠道疼痛性疾病以及疼痛、恶心和呕吐的具体症状的数据。这些信息被整合到一份最终文件中，该文件综合了现有证据，并根据委员会专家的研究和临床经验，为临床使用提供建议。
由于有限的对照试验，FGID 中枢神经调节剂的基于证据的综述与开放标签研究和病例系列一起，结合专家经验，使用共识（德尔菲）方法创建了建议。由于条件的多样性和治疗选择的复杂性，针对不同的 FGIDs 生成了具体的建议。然而，一些一般性建议包括：（1）低至中等剂量的三环类抗抑郁药为治疗慢性胃肠道疼痛和疼痛性 FGIDs 提供了最令人信服的益处证据，也可以推荐使用血清素去甲肾上腺素再摄取抑制剂，但需要进一步研究；（2）当单一药物无效或高剂量产生副作用时，建议进行增效治疗，即添加第二种治疗药物（添加喹硫平、阿立哌唑、丁螺环酮 α2δ 配体药物）；（3）治疗应持续 6-12 个月，以潜在预防复发；（4）实施成功的治疗需要有效的沟通技巧，以提高患者的接受度和依从性，并优化医患关系。
基于系统和有针对性的综述以及多学科小组的共识，我们提供了中枢神经调节剂治疗慢性胃肠道症状和 FGIDs 的使用摘要信息和指南。需要进一步的研究来证实和完善这些建议。
