P409 Using antidepressants for refractory symptoms of Inflammatory Bowel Disease: a prospective service evaluation
Moulton, C.(1)*;Avery, P.(2);Hart, A.(3);
(1)St Mark's Hospital, Psychological Medicine Unit, London, United Kingdom;(2)St Mark's Hospital, Inflammatory Bowel Disease Nursing Team, London, United Kingdom;(3)St Mark's Hospital, St Mark's Academic Institute, London, United Kingdom;
Background
One third of patents with inflammatory bowel disease (IBD) have refractory gastrointestinal symptoms, such as pain and diarrhoea, even after exhaustion of medical therapies. A further 40% have persistent fatigue. Although antidepressants can improve such symptoms, their role in treatment-refractory IBD has not been studied.
Methods
We evaluated a Consultant Psychiatrist clinic for patients with refractory IBD symptoms. Patients were reviewed remotely over 3-6-month follow-up. For pain, we used duloxetine or venlafaxine first-line. For nausea and insomnia-driven fatigue, we used mirtazapine first-line. For refractory fatigue or diarrhoea, we used bupropion, reboxetine or vortioxetine. Ineffective medications were changed after 6-8 weeks. Antidepressants were combined and augmented with antipsychotic if required. The primary outcome was change in the self-report IBD Control Questionnaire, scored from 0 (poor) to 16 (good). Secondary outcomes were changes in depression (PHQ-9), anxiety (GAD-7), IBD Fatigue Scale and average daily bowel frequency. Data were presented as mean (SD) if parametric and median [interquartile range] if skewed. Changes over time were measured using 2-tailed paired t-tests (parametric) or Wilcoxon signed rank tests (skewed data).
Results
Of 62 patients with IBD offered antidepressants, 80.1% started treatment. Mean age was 41.8 years and mean IBD duration 16.6 years. Of these, 88% had Crohn’s disease, 70% were refractory to multiple biologics, 62% had previous bowel resection and 14% had intestinal failure. At baseline, 92% had severe fatigue (IBD-Fatigue >10), 52% had diarrhoea/high stoma output, 50% had pain and 18% nausea/vomiting. At baseline, 86% met ICD-10 criteria for moderate/severe depression and/or generalised anxiety disorder, and 26% had existing treatment-resistant depression.
At follow-up, IBD Control score improved from 1.5 [0-4] to 5 [1.5-8] (p<0.001), as did depression (mean 24% reduction, p<0.001), anxiety (mean 28% reduction, p<0.001) and fatigue (mean 18% reduction, p=0.01). Although 27% of patients responded to first-line antidepressants, the rest required changes in treatment, combination therapy or augmentation. Ultimately, 51.5% were prescribed bupropion, reboxetine or vortioxetine, collectively in whom median bowel frequency fell from 6/day to 4/day (p<0.001). Only 8% could not tolerate antidepressants.
Conclusion
Even in very difficult-to-treat IBD, antidepressants can improve IBD control, depression, anxiety and fatigue. However, specialist- or combination antidepressants are often required in this specific group. Clinical services should consider expansion of psychiatry provision to improve IBD outcomes. Trials of antidepressants for patients with refractory IBD symptoms are needed.