Abstract
Chronic vomiting in diabetic patients often is unresponsive to prokinetic agents and poorly explained by delayed gastric emptying or neuropathy. This retrospective study examines clinical response to tricyclic antidepressants, a treatment of reported benefit in nondiabetic patients with unexplained vomiting syndromes. Outcomes were studied in 24 diabetic outpatients who had been treated with tricyclic antidepressants specifically for nausea and vomiting after an unsatisfactory response to prokinetic therapy. Symptom patterns and treatment response were determined from chart review and telephone interview. Ten patients (42%) had recurrent, stereotypical vomiting episodes with symptom-free intervals suggesting cyclic vomiting syndrome; 14 (58%) had persistent symptoms. By chart review, at least moderate symptom response to tricyclic antidepressant treatment (median dosage, 50 mg/day) occurred in 88% of subjects, with complete or nearly complete resolution of symptoms in one-third. At follow-up interview, 77% self-reported at least moderate symptom improvement during therapy and 68% rated tricyclic antidepressants the most effective treatment received. Duration of diabetes, presence of neuropathy, and psychiatric status were not predictive of treatment outcome in multivariate analysis, but a cyclical symptom pattern attenuated antidepressant response (P< 0.05). In this retrospective review, the majority of diabetic patients with chronic vomiting and incomplete response to prokinetic therapy benefited from tricyclic antidepressants in low-dose, open-label regimens and rated them the most effective treatment received. This therapeutic option should be further studied in diabetic patients considering the morbidity of chronic vomiting in this population.
Similar content being viewed by others
References
Siddique R, Nguyen M, Farup C (1998) Cost of hospitalization for diabetic patients with vomiting: evidence from a national survey. Gastroenterology 114:A41
O’Donovan D, Feinle-Bisset C, Jones K, Horowitz M (2003) Idiopathic and diabetic gastroparesis. Curr Treat Options Gastroenterol 6:299–309
Smith DS, Ferris CD (2003) Current concepts in diabetic gastroparesis. Drugs 63:1339–1358
Clouse RE, Lustman PJ (2002) Case study: persistent vomiting in a patient with type 2 diabetes. Clin Diabetes 20:39–41
O’Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K (1999) Antidepressant therapy for unexplained symptoms and syndromes. J Fam Pract 48:980–990
Jackson JL, O’Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K (2000) Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med 108:65–72
Lesbros-Pantoflickova D, Michetti P, Fried M, Beglinger C, Blum AL (2004) Meta-analysis: the treatment of irritable bowel syndrome. Aliment Pharmacol Ther 20:1253–1269
Prakash C, Lustman PJ, Freedland KE, Clouse RE (1998) Tricyclic antidepressants for functional nausea and vomiting: clinical outcome in 37 patients. Dig Dis Sci 43:1951–1956
Li BU (2000) Cyclic vomiting syndrome. Curr Treat Options Gastroenterol 3:395–402
Prakash C, Staiano A, Rothbaum RJ, Clouse RE (2001) Similarities in cyclic vomiting syndrome across age groups. Am J Gastroenterol 96:684–688
Prakash C, Clouse RE (1999) Cyclic vomiting syndrome in adults: Clinical features and response to tricyclic antidepressants. Am J Gastroenterol 94:2855–2860
Jones KL, Russo A, Stevens JE, Wishart JM, Berry MK, Horowitz M (2001) Predictors of delayed gastric emptying in diabetes. Diabetes Care 24:1264–1269
Kendall BJ, Kendall ET, Soykan I, McCallum RW (1997) Cisapride in the long-term treatment of chronic gastroparesis: a 2-year open-label study. J Int Med Res 25:182–189
Loo FD, Palmer DW, Soergel KH, Kalbfleisch JH, Wood CM (1984) Gastric emptying in patients with diabetes mellitus. Gastroenterology 86:485–494
de Caestecker JS, Ewing DJ, Tothill P, Clarke BF, Heading RC (1989) Evaluation of oral cisapride and metoclopramide in diabetic autonomic neuropathy: an eight-week double-blind crossover study. Aliment Pharmacol Ther 3:69–81
Brown CK, Khanderia U (1990) Use of metoclopramide, domperidone, and cisapride in the management of diabetic gastroparesis. Clin Pharm 9:357–365
Snape WJ Jr, Battle WM, Schwartz SS, Braunstein SN, Goldstein HA, Alavi A (1982) Metoclopramide to treat gastroparesis due to diabetes mellitus: a double-blind, controlled trial. Ann Intern Med 96:444–446
Ricci DA, Saltzman MB, Meyer C, Callachan C, McCallum RW (1985) Effect of metoclopramide in diabetic gastroparesis. J Clin Gastroenterol 7:25–32
Abell T, McCallum R, Hocking M, Koch K, Abrahamsson H, Leblanc I, Lindberg G, Konturek J, Nowak T, Quigley EM, Tougas G, Starkebaum W (2003) Gastric electrical stimulation for medically refractory gastroparesis. Gastroenterology 125:421–428
Tack J, Bisschops R, Sarnelli G (2004) Pathophysiology and treatment of functional dyspepsia. Gastroenterology 127:1239–1255
Talley NJ, Verlinden M, Jones M (2001) Can symptoms discriminate among those with delayed or normal gastric emptying in dysmotility-like dyspepsia? Am J Gastroenterol 96:1422–1428
Clouse RE (2006) Management of dyspepsia. In: Wolfe MM, David GL, Farraye FA, Giannella RA, Malagelada J-R, Steer ML (eds) Therapy of digestive disorders, 2nd ed. Elsevier, London (in press).
Clouse RE, Lustman PJ (2005) The use of psychopharmacological agents for functional gastrointestinal disorders. Gut 54:1332–1341
Hasler WL, Chey WD (2003) Nausea and vomiting. Gastroenterology 125:1860–1867
Bytzer P, Talley NJ, Leemon M, Young LJ, Jones MP, Horowitz M (2001) Prevalence of gastrointestinal symptoms associated with diabetes mellitus: a population-based survey of 15,000 adults. Arch Intern Med 161:1989–1996
Maleki D, Locke GR 3rd, Camilleri M, Zinsmesiter AR, Yawn BP, Leibson C, Melton LJ 3rd (2000) Gastrointestinal tract symptoms among persons with diabetes mellitus in the community. Arch Intern Med 160:2808–2816
Mjornheim AC, Finizia C, Blohme G, Attvall S, Lundell L, Ruth M (2003) Gastrointestinal symptoms in type 1 diabetic patients, as compared to a general population. A questionnaire-based study. Digestion 68:102–108
Anderson RJ, Freedland KE, Clouse RE, Lustman PJ (2001) The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 24:1069–1078
Grigsby AB, Anderson RJ, Freedland KE, Clouse RE, Lustman PJ (2002) Prevalence of anxiety in adults with diabetes: a systematic review. J Psychosom Res 53:1053–1060
Lustman PJ, Anderson R, Freedland KE, de Groot M, Carney RM, Clouse RE (2000) Depression and poor glycemic control: a meta-analyitc review of the literature. Diabetes Care 23:934–942
Anderson RJ, Grigsby AB, Freedland KE, de Groot M, McGill JB, Clouse RE, Lustman PJ (2002) Anxiety and poor glycemic control: a meta-analytic review of the literature. Int J Psych Med 32:235–247
Clouse RE, Lustman PJ, Freedland KE, Griffith LS, McGill JB, Carney RM (2003) Depression and coronary heart disease in women with diabetes. Psychosom Med 65:376–383
Lustman PJ, Griffith LS, Clouse RE, Freedland KE, Eisen SA, Rubin EH, Carney RM, McGill JB (1997) Effects of nortriptyline on depression and glycemic control in diabetes: results of a double-blind, placebo-controlled trial. Psychosom Med 59:241–250
Lustman PJ, Clouse RE, Nix BD, Freedland KE, Rubin EH, McGill JB, Williams MM, Gelenberg AJ, Ciechanowski PS, Hirsch IB (2006) Sertraline for prevention of depression recurrence in diabetes: a randomized, double-blind, placebo-controlled trial. Arch Gen Psychiatry 63:521–529
Okamura F, Tashiro A, Utumi A, Imai T, Suchi T, Tamura D, Sato Y, Suzuki S, Hongo M (2000) Insulin resistance in patients with depression and its changes during the clinical course of depression: minimal model analysis. Metabolism 49:1255–1260
Clouse RE, Lustman PJ (1989) Gastro-intestinal symptoms in diabetic patients: lack of association with neuropathy. Am J Gastroenterol 84:868–872
Talley NJ, Howell S, Jones MP, Horowitz M (2002) Predictors of turnover of lower gastrointestinal symptoms in diabetes mellitus. Am J Gastroenterol 97:3087–3094
Gorard DA, Libby GW, Farthing MJ (1995) Effect of a tricyclic antidepressant on small intestinal motility in health and diarrhea-predominant irritable bowel syndrome. Dig Dis Sci 40:86–95
Drossman DA, Toner BB, Whitehead WE, et al. (2003) Cognitive-behavioral therapy vs. education and desipramine vs. placebo for moderate to severe functional bowel disorders. Gastroenterology 125:19–31
Clouse RE (2003) Antidepressants for irritable bowel syndrome. Gut 52:598–599
Rohde A, Dembinski J, Dorn C (2003) Mirtazapine (Remergil) for treatment resistant hyperemesis gravidarum: rescue of a twin pregnancy. Arch Gynecol Obstet 268:219–221
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sawhney, M.S., Prakash, C., Lustman, P.J. et al. Tricyclic Antidepressants for Chronic Vomiting in Diabetic Patients. Dig Dis Sci 52, 418–424 (2007). https://doi.org/10.1007/s10620-006-9378-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-006-9378-8