Tricyclic Antidepressants for Chronic Vomiting in Diabetic Patients

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.

Gastric emptying and glycaemia in health and diabetes mellitus

“…170 A retrospective study has also suggested that use of tricyclic antidepressants decreased nausea in patients with diabetes mellitus, approximately one-third of whom had delayed gastric emptying. 171 However, in a randomized placebo-controlled trial, use of nortriptyline was not associated with symptomatic improvement in patients with idiopathic gastroparesis. 172 Effects of glycaemia on drug efficacy The prokinetic effects of erythromycin have been shown to be markedly attenuated in the setting of hyperglycaemia.…”

Symptomatic Management for Gastroparesis

“…28 In a follow-up analysis of 24 diabetics with refractory nausea and vomiting, tricyclics at median doses of 50 mg reduced symptoms in 88% and abolished them in nearly onethird. 29 Twenty-nine percent of patients showed delayed gastric emptying. Taken together, these observations suggested potential utility of tricyclics to reduce nausea, vomiting, and pain in gastroparesis.…”

Gastroparese

“…Bestätigende Studien fehlen allerdings. Trizyklische Antidepressiva, eingesetzt in einer niedrigen Dosierung zur Behandlung von refraktärer Übelkeit und Erbrechen bei DG und IG, zeigten positive Effekte auch im Hinblick auf Abdominalschmerzen [28]. Die bekannten anticholinergen Effekte, z.…”