A lengthy report (DA Drossman et al. Gastroenterol 2018; 154: 1140-71) thoroughly reviews the evidence for neuromodulators for functional GI disorders, including Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome.

“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.”

The report makes specific recommendations for several functional conditions (Table 4).

• For dyspepsia, the authors recommend categorizing as either postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) as per Rome IV criteria.
• They state that “Buspirone…may be used for PDS where early satiety, fullness and nausea predominate.”
• “Mirtazapine is a good treatment option for PDS when there is chronic nausea and vomiting, or weight loss, and it may also help coexisting abdominal pain.”
• For EPS, “studies mainly support the use of TCAs, either initially or after an unsuccessful response to a proton pump inhibitor.”

Figure 5 outlines general treatment advice:

• SSRIs -“when anxiety, depression and phobic features are prominent with FGIDs”
• TCAs -“first-line treatment when pain is dominant in FGIDs”
• Tetracyclic antidepressant (mirtazapine, mianserin, trazodone) -“treatment of early satiety, nausea/vomiting, weight loss and disturbed sleep”
• SNRIs (duloxetiine, venlafaxine, desvenlafaxin, milnacipran) -“treatment when pain is dominant in FGIDs or when side effects from TCAs preclude treatment”
• Augmentation therapies are subsequently delineated including atyipical antipsychotics, pyschological treatments (like cognitive behavioral therapy) and hypnosis

Related blog posts:

• Brave New World: Psychotropic Manipulation & Pediatric Functional GI Disorders
• Amplified Pain Syndromes in Children
• Brain-Gut Axis in 2017
• Will I Have This Stomach Pain Forever? (Part 1) | gutsandgrowth
• A 6-Year Study of Amitriptyline, Escitalopram, and Functional Dyspepsia | gutsandgrowth
• Dreaded Nausea (2017) | gutsandgrowth
• Mirtazapine for Functional Dyspepsia | gutsandgrowth
• Advice on Abdominal Pain for Everyone Who Cares for Children | gutsandgrowth
• AGA Guidelines on Medicines for Irritable Bowel
• Change the Name: “Functional” is Lousy | gutsandgrowth
• Anxiety and Functional Abdominal Pain | gutsandgrowth
• Cognitive Behavioral Therapy for Childhood Abdominal Pain …
• Pain changes brain | gutsandgrowth
• Acupuncture for irritable bowel syndrome | gutsandgrowth

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.