Clouse R E, Lustman P J, Geisman R A, Alpers D H
Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri.
Aliment Pharmacol Ther. 1994 Aug;8(4):409-16. doi: 10.1111/j.1365-2036.1994.tb00308.x.
Antidepressant agents may have a therapeutic role in functional gastroenterologic disorders, but controlled investigations in irritable bowel syndrome (IBS) have not provided satisfactory practice recommendations. To help with future study design, we reviewed a five-year clinical experience with antidepressant agents in out-patients with IBS.
Presenting features, treatment course, and clinical outcome were determined from a chart review of 138 patients attending a university-based gastroenterology practice.
Patients were treated with up to five antidepressants in separate, consecutive trials if a satisfactory end-point had not been reached. Tricyclic antidepressants were utilized 130 times, newer antidepressants 39 times, and anxiolytic-antidepressants 47 times. Improvement and complete remission in bowel symptoms occurred in 89% and 61% of patients, respectively, during antidepressant therapy. Median dosages being prescribed when remission occurred were less than those conventionally used in clinical psychiatry (50 mg/day for several tricyclic antidepressants). Age, gender, symptom duration, and presence of psychological symptoms did not discriminate those who remitted from those who did not, whereas a pain predominant symptom pattern was more commonly associated with symptom remission (P < 0.05 comparing symptom patterns). Symptom remission was more likely during the first antidepressant treatment than with subsequent trials in the group with continued symptoms (P = 0.01), but nearly half of the patients with side effects or no benefit from the first agent who went on to subsequent trials remitted during treatment with an alternative antidepressant.
The design of this retrospective review is not capable of determining the efficacy of antidepressants for IBS. Our observations in conjunction with other available data suggest that future trials should employ low daily dosages, carefully assess pain response, include patients with and without active psychiatric symptoms, and utilize a second agent for subjects intolerant or unresponsive to the first.
抗抑郁药可能在功能性胃肠疾病中发挥治疗作用，但对肠易激综合征（IBS）的对照研究尚未提供令人满意的实践建议。为了有助于未来的研究设计，我们回顾了五年间在IBS门诊患者中使用抗抑郁药的临床经验。
通过对138名在大学胃肠病科就诊患者的病历回顾，确定其临床表现、治疗过程和临床结果。
如果未达到满意的终点，则在单独的连续试验中，患者最多接受五种抗抑郁药治疗。三环类抗抑郁药使用了130次，新型抗抑郁药使用了39次，抗焦虑抑郁药使用了47次。在抗抑郁治疗期间，分别有89%和61%的患者肠道症状得到改善和完全缓解。症状缓解时的中位处方剂量低于临床精神病学中常规使用的剂量（几种三环类抗抑郁药为50毫克/天）。年龄、性别、症状持续时间和心理症状的存在并不能区分缓解者和未缓解者，而以疼痛为主的症状模式更常与症状缓解相关（比较症状模式时P<0.05）。在有持续症状的组中，首次抗抑郁治疗期间症状缓解的可能性比后续试验更高（P=0.01），但在首次用药出现副作用或无疗效而继续进行后续试验的患者中，近一半在改用另一种抗抑郁药治疗期间症状缓解。
这项回顾性研究的设计无法确定抗抑郁药对IBS的疗效。我们的观察结果与其他现有数据表明，未来的试验应采用低日剂量，仔细评估疼痛反应，纳入有或无活动性精神症状的患者，并为对第一种药物不耐受或无反应的受试者使用第二种药物。
