Anticholinergic, anti‐depressant and other medication use is associated with clinically relevant oesophageal manometric abnormalities

Abstract

Background: Medications can affect gastrointestinal tract motility. However, their effects on oesophageal motility in particular are often not as widely known or may be underestimated. Aim:To review the effect of existing medication use on high-resolution oesophageal manometry (HRM) in a 'real-world' setting.Methods: Adult patients with upper gut symptoms and normal endoscopy or imaging who had HRM over a 22-month period were analysed. Achalasia and major disorders of peristalsis were excluded. All medications taken within 24 hours of the procedure were prospectively recorded and compared with HRM results, controlling for age, gender and proton pump inhibitor use.Results: A total of 502 patients (323 female, mean age 51) were recruited. Of these, 41.2% had normal oesophageal HRM, while 41.4% had ineffective oesophageal motility (IOM) and 7.6% had oesophagogastric junction outflow obstruction (OGJOO). Serotonin/norepinephrine reuptake inhibitors (SNRI) and opioids were associated with significantly higher resting lower oesophageal sphincter pressure.Benzodiazepines and opioids were associated with elevated integrated relaxation pressure. SNRI and inhaled beta-agonists were associated with increased distal contractile index, whereas calcium channel blockers were associated with a lower distal contractile index. Odds ratio of being on anticholinergics was higher in IOM patients vs normal (3.6, CI 1.2-10.8). Odds ratio for anticholinergics, inhaled betaagonists, anticonvulsants, SNRIs and opioids (trend) were all > 3 for OGJOO patients vs normal. Conclusion:Many medication classes are associated with abnormal HRM variables and diagnoses such as OGJOO and IOM; some of these associations are probably causal. These possible links should be taken into consideration during manometry interpretation.

Evaluating the Non-conventional Achalasia Treatment Modalities

“…Serotonin and norepinephrine reuptake inhibitors are antidepressants and act by binding to the serotonin and norepinephrine transporters (73). Serotonin and norepinephrine reuptake inhibitors also act in the lower esophageal function (Level 2b; Grade: B) (74,75). However, no study addresses their use in achalasia patients, and consequently, their use should be restricted to research protocols (Level 5; Grade: D).…”

“…Opioids inhibit excitatory neurotransmitter release (76), and benzodiazepines inhibit smooth muscle contraction (77). Benzodiazepines and opioids are associated with elevated integrated relaxation pressure (Level 1b; Grade: A) (75,78). However, no study addresses their use in achalasia patients, and their administration should be considered only for research protocols (Level 5; Grade: D).…”

The Impact of Medications on Esophageal Motility

“…38 A recent study from 2020 using HRM found calcium channel blockers were associated with a lower distal contractile integral (DCI). 39 Further study is needed to evaluate the impact of nifedipine and diltiazem on HRM using updated Chicago classification version 4.0 criteria for hypercontractile esophagus and DES.…”

“…46 Most recently a study of 502 patients undergoing HRM found patients taking anticholinergics were more likely to have IEM (OR 3.6, CI 1.2-10.8) and patients taking TCAs were more likely to have esophagogastric outflow obstruction (OR 2.8, CI 1.1-7.0). 39…”

Is EGJOO a Purely Manometric Diagnosis?

“…19 Other medications including anticholinergics, serotonin/norepinephrine reuptake inhibitors (SNRI), benzodiazepines, and tricyclic antidepressants have also been associated with EGJOO but are not as well-studied. 20…”