Inflammatory bowel disease, or IBD, is characterized by severe diarrhea, pain, fatigue and weight loss. It’s frustrating at best, debilitating at worst.
Because IBD is an inflammatory condition, resulting from an abnormal response to the body’s immune system, it’s usually treated with anti-inflammatory medications. Sometimes these are very effective at improving patients’ symptoms.
And sometimes they’re not. For many IBD patients treated with anti-inflammatory drugs, symptoms persist even after the inflammation is well-controlled.
“As a clinician, when this happens you continue to seek something to improve the patient’s quality of life,” says Matthew Ciorba, MD, gastroenterologist at Washington University School of Medicine.
IBS vs. IBD
So for the past several years, Ciorba and colleagues have been using an entirely different kind of medication: tricyclic antidepressants, which were among the earliest developed anti-depressants. These ‘tricyclics,’ as they are known, are widely considered to be effective in treating another gastrointestinal disorder, irritable bowel syndrome (IBS), which doesn’t involve the same level of inflammation as IBD. And in many patients, symptoms improve.
“In these types of patients, the presentation is typically one that parallels what you see in IBS,” says gastroenterologist Gregory Sayuk, MD, MPH. “If you didn’t know the patient had IBD, you would assume you were looking at IBS. So it made sense to use treatments that work in IBS, and tricyclics are one of the better options.”
The clinical results were promising enough to prompt the researchers to gather data. “We’ve been doing this clinically for a while and thought it would be worth reporting in an objective way what we’ve found clinically to be effective,” Sayuk says.
Ciorba, Sayuk and colleagues performed a retrospective study to examine how well tricyclic antidepressant therapy worked in IBD patients who had residual symptoms despite controlled inflammation. They included 81 IBD patients and, for comparison, 77 IBS patients treated with the drugs. Almost 60 percent of the IBD patients experienced at least moderate improvement of symptoms. In comparison, symptoms improved in 46 percent of the IBS patients.
“The bottom line is that tricyclic antidepressant treatment is safe and well-tolerated in these patients and makes them feel better,” Ciorba says.
The usual treatment approach in IBD patients with controlled inflammation but persistent symptoms is to increase the dose of anti-inflammatory drugs or switch to a stronger anti-inflammatory, says Sayuk. But this is often not effective and sometimes harmful, as anti-inflammatories can increase the risk of infections and even cancer.
“It’s worth considering the possibility that other things are safer and more effective than anti-inflammatory therapy,” Sayuk says. He adds that it would be nice to do a study comparing patients who were prescribed either anti-inflammatory or anti-depressant therapy. “My strong suspicion is that the latter would be more effective.”
Tricyclic antidepressants are cost-effective for patients as well—costing far less than anti-inflammatory medications.
“This is an exciting crossroad where we are taking kind of an obvious strategy and bridging it to a different field,” Sayuk says. “This is not rocket science or a great breakthrough—tricyclics have been available for decades—but it can make a big difference to these patients.”