Читать книгу The Esophagus - Группа авторов - Страница 42

As a class, the SSRIs and SNRIs have the largest number of studies for the treatment of esophageal hypersensitivity. Among these, Lee et al. randomized 43 patients with functional chest pain to four weeks of venlafaxine 75 mg extended‐release daily or placebo and found a positive response in 52% vs. 4% (p < 0.001) in addition to greater improvement in body pain and emotional role (p = 0.002) [89]. Similarly, Doraiswamy et al. enrolled 50 patients with NCCP for a randomized, double‐blind, placebo‐controlled eight‐week trial of paroxetine 10–50 mg daily, showing paroxetine‐treated patients had a significant improvement in the Clinical Global Impressions scale (p < 0.05) [90].

Looking more closely at the effect of SSRIs on motility, Broekaert et al. administered intravenous citalopram 20 mg to 10 patients with established esophageal hypersensitivity undergoing esophageal manometry with mechanical and chemical stimulation via balloon distension and acid infusion. [91]. These authors found that citalopram did not significantly alter esophageal motility; however, it increased the threshold for the first perception (p < 0.005) and discomfort (p < 0.01) of balloon distension as well as prolonged the time for perception (p < 0.005) and discomfort (p < 0.001) of heartburn with acid infusion [91]. These results suggest that administration of citalopram, even in the acute setting, may reduce esophageal hypersensitivity without affecting esophageal motility.

Other studies have looked at the role of SSRIs as monotherapy or in combination with nonpharmacological treatment. Varia et al. conducted a double‐blind, placebo‐controlled study of sertraline 50–200 mg daily in 30 patients with noncardiac chest pain. These patients used subjective reporting with the Beck Depression Inventory and daily pain diaries during the nine‐week trial period. Overall, patients in the sertraline group demonstrated a clinically significant reduction in the reporting of daily pain (p = 0.02) [92]. In addition, the role of sertraline in noncardiac chest pain was evaluated by Keefe et al., who randomized 115 patients to receive coping skills training (CST) and sertraline 50–200 mg daily, alone or in combination, vs. placebo [93]. These authors found that sertraline alone was able to decrease reported pain intensity and unpleasantness, but not anxiety or pain catastrophizing, whereas CST was the only means effective for pain catastrophizing; therefore, these authors suggest that the combination of CST and sertraline rather than either alone may result in the greatest benefit [93].

Finally, Spinhoven et al. randomized 69 patients with NCCP to 16 weeks of cognitive‐behavioral therapy (CBT), paroxetine 10–40 mg daily, or placebo. Daily pain diaries and anxiety questionnaires were used to monitor patient outcomes [94]. Overall, CBT was more effective than placebo, but not paroxetine, at decreasing patient’s perceived anxiety at mid‐treatment (p = 0.02) and post‐treatment (p = 0.01) evaluations [94]. No significant improvement was seen for paroxetine compared to placebo [94].