title: 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.
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, St Louis, MO 63110, USA.
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Sawhney
authors.forename: Chandra
authors.initials: C
authors.lastname: Prakash
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Lustman
authors.forename: Ray E
authors.initials: RE
authors.lastname: Clouse
mesh_terms: D000328:Adult; D000368:Aged; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage / Q000627:therapeutic use*; D000932:Antiemetics / Q000008:administration & dosage / Q000627:therapeutic use*; D002908:Chronic Disease; D003922:Diabetes Mellitus, Type 1 / Q000150:complications*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000188:drug therapy / Q000209:etiology; D017060:Patient Satisfaction; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014839:Vomiting / Q000188:drug therapy* / Q000209:etiology
chemical_list: D000929:Antidepressive Agents, Tricyclic; D000932:Antiemetics