Use of Antidepressant Medications to Treat Recurrent Abdominal Pain

A recent study (C AM Zar-Kessler et al. JPGN 2017; 65: 16-21) retrospectively reviewed a single center’s 8 year experience (2005-2013) using antidepressant medications to treat nonorganic abdominal pain. Of 531 cases, 192 initiated treatment with either a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).

Key findings:

  • 63 of 84 (75%) of SSRI-treated patients improved; 56 of 92 (61%) of TCA-treated patients improved.  The higher response rate to SSRIs persisted after control for psychiatric factors.
  • A much higher percentage of SSRI-treated patients, compared to TCA-treated patients, had anxiety (49% vs 22%); an additional 15% and 5%, respectively, had combined anxiety/depression.
  • The most common SSRI in this study was citalopram with median dose of 10 mg (range 5-60 mg).
  • The most common TCA in this study was nortriptyline with median dose of 20 mg (range 10-50).
  • Similar numbers of patients in each group had adverse effects, include 21 (25%) of SSRI-treated patients and 20 (22%) of TCA-treated patients.  14% of SRRI-treated patients discontinue medication due to adverse effects, compared with 17% of TCA-treated patients.
  • Mood disturbances were higher in this study among TCA-treated patients: 14% compared with 6% of SSRI-treated patients
  • TCAs were prescribed by gastroenterologists in 88% of cases; with SSRIs, only 39% of prescriptions were from gastroenterologists.

In the discussion, the authors note that “all patients who experienced GI adverse effect were prescribed medications that would worsen their underlying bowel complaint…these issues may have been mitigated if more attention was paid” to this.  “Specifically, TCAs should be used cautiously in those with constipation, whereas SSRIs should be avoided in those with diarrhea.”

My take: This study shows that both classes of antidepressants were associated with improvement.  The conclusions about effectiveness are limited as this is a retrospective study and could not control/evaluate many variables. That being said, particularly if there is coexisting anxiety, as was frequent in this study population, a SSRI may be more effective.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Tynn Church, Prague

 

Long-term Effects on Bone Health of PPIs in Infancy?

A recent study –summarized by Pediatric News (MDedge): Antacid use in infants linked to increased fracture risk.

In this large study (874,447 children), more than 90% of the cohort had not received a prescription for any antacid.

An excerpt:

The large study revealed that use of proton pump inhibitors (PPIs) before age 1 year was linked to a 22% increased risk of fracture, compared with those not prescribed antacids…

The retrospective study’s cohort comprised 874,447 children born between 2001 and 2013 who had been in the U.S. Military Health System for at least 2 years…

Adjustment for preterm birth, low birth weight, sex, and a previous fracture barely reduced those risks: 22% increased risk for PPI use, 4% increased risk for H2 blocker use, and 31% increased risk for using both. The vast majority of children who took antacids had been prescribed them in their first 6 months, so the researchers calculated adjusted risk by age of exposure. 

My take: There are a lot of reasons to resist using PPIs in most infants, particularly lack of efficacy.  Potential harms of these medications, particularly at the youngest ages, should not be overlooked either.

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Antibiotics for Acute Uncomplicated Appendicitis in Children

A recent meta-analysis study (L Huang et al. JAMA Pediatr 2017; 17: 426-34 -thanks to Ben Gold for this reference) indicates that antibiotcis can be effective as treatment for acute uncomplicated appendicitis, particularly if no appendolith is present.

From the abstract:

Abstract

IMPORTANCE:

Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial.

OBJECTIVE:

To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients.

STUDY SELECTION:

Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days.

RESULTS:

A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%).

CONCLUSIONS AND RELEVANCE:

This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

From a AHC Media synopsis of article:Although antibiotic treatment of acute appendicitis appears effective in many cases, there is a nearly nine-fold higher risk of treatment failure compared with appendectomy, with 26.8% of patients in the antibiotic treatment group requiring interval appendectomy.

My take: My opinion is that surgery is appropriate as first-line treatment for  acute uncomplicated appendicitis.

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Adalimumab Can Reverse Growth Failure in Pediatric Crohn’s Disease

In an industry-sponsored study (TD Walters et al. Inflamm Bowel Dis 2017; 23: 967-75), adalimumab (ADA) was shown to be effective agent in reversing growth failure associated with pediatric Crohn’s disease (CD).

Background:  About one-third of children and adolescents with CD suffer from growth failure and delayed puberty.  Several prior studies have shown that anti-TNF therapy can improve height velocity and that early treatment with anti-TNF therapy (≤3 months after diagnosis) leads to greater improvement in height obtained, if initiated before puberty or early into puberty. This study examines the effectiveness of ADA in children from the IMAgINE 1 trial.

The authors identified 73 participants with growth delays (& adequate data) along with 27 participants with no growth delays.

Key findings:

  • ADA therapy significantly improved and normalized growth rates at 26 and 52 weeks in patients with baseline linear growth impairment.
  • At week 26, height velocity z-score was 1.33 among 23 children in remission compared with -0.78 (n=29) among “nonremitters”
  • At week 52, height velocity z-score was 2.17 among 27 children in remission compared with -1.57 (n=17) among “nonremitters”

My take: In moderate to severe CD, anti-TNF agents have been demonstrated to reverse growth failure; though, this is expected to occur only in patients with clinical response. To my knowledge, no other CD medical therapies have been proven to reverse growth failure (surgical treatment can improve growth as well).

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Small Pediatric Study: Probiotic Helping Some with Irritable Bowel Syndrome

In a recent study (O Jadresin et al. JPGN 2017; 64: 925-9), 55 children with functional abdominal pain or irritable bowel syndrome were randomized (prospective, double-blind, placebo-controlled study) to either L reuteri DSM or placebo.

Key findings:

  • The intervention group had more days without pain: median 89.5 days vs. 51 days (P=.029)
  • Abdominal pain was less severe in the intervention group at some time points (second month, and fourth month)
  • The two groups did not differ with regard to duration of abdominal pain, stool type, or absence from school

Limitation: Small number of patients -the estimated samples size was not reached

My take: This study suggests that probiotics may help some pediatric patients with irritable bowel syndrome.  Trying to identify which patients should receive a probiotic and which probiotic should be selected remains unclear.

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Five Reasons Medical Groups Oppose the Senate’s AHCA

Many analysts have described the American Health Care Act (AHCA) as essentially an 800 billion dollar tax cut which as a consequence eliminates health care coverage for more than 20 million.

Some of the reasons why almost all major medical groups oppose the repeal/replace effort of the Affordable Care Act are summarized from NBC News. In brief, they are the poor, the elderly, children, women, and those with preexisting conditions –all disadvantaged if the AHCA passes.

NBC News: Just About Every Major Medical Group Hates the GOP Healthcare

An excerpt -regarding children:

Medicaid covers 75 million people, including nearly 36 million children, according to data released Friday by the Center for Medicare and Medicaid Services..

“Senate leaders present their bill as providing states with flexibility. The reality is that it will put considerable pressure on states to limit their spending on health care, including for children,” said Dr. Matthew Davis, a professor of pediatrics and of medicine at Northwestern University Feinberg School of Medicine.

“The bill includes misleading ‘protections’ for children by proposing to exempt them from certain Medicaid cuts,” added Dr. Fernando Stein, president of the American Academy of Pediatrics.

“A ‘carve-out’ for children with ‘medically complex’ health issues does little to protect their coverage when the base program providing the coverage is stripped of its funding. Doing so forces states to chip away coverage in other ways, by not covering children living in poverty who do not have complex health conditions, or by scaling back the benefits that children and their families depend on,” Stein added.

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Updated Pediatric Helicobacter Pylori Guidelines

Joint ESPGHAN/NASPGHAN guidelines (NL Jones et al. JPGN 2017; 64: 991-1003) have been published.  Overall, these guidelines cover a great deal of information.  It is interesting that these guidelines provide some conflicting advice with recommendations for adults.

  • Some recommendations:
    The authors recommend against diagnostic testing H pylori in children with functional abdominal pain
  • The authors recommend against using antibody-based tests from blood, urine, or saliva.
  • The authors recommend noninvasive testing for H pylori when investigating chronic immune thrombocytopenic purpura (ITP)
  • First line therapy recommendations if sensitivity is unknown: High-dose PPI-Amoxicillin-Metronidazole for 14 days OR Bismuth-based quadruple therapy (in children less than 8 years, quadruple therapy would be bismuth, PPI, amoxicillin and metronidazole; in older children it is recommended to substitute tetracycline for amoxicillin).  Specific dosing is given in this report (Table 3 and Table 4)
  • The authors recommend assessing for infection eradication at least 4 weeks after completion of therapy

My take: I favor quadruple therapy for most patients (see adult guidelines below) until sensitivities can be more easily obtained.  If you know of a reliable lab to obtain culture sensitivities, please let me know.

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Adult Guidelines:

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