Elavil and Bowel Function

[Katie 2]

Hello - after struggling with irritable bowel for 3plus years,
I recently began taking Elavil which has been a godsend for
alleviating abdominal pain - The only thing that remains
is "phantom" pain because I was so used to the lower abdominal
pain. However, my stool consistency is still loose, and the
stools break apart. Can you tell me whether this is normal
and will eventually go away or whether I should not expect
to be totally "cured" by the Elavil?? Also would a probiotic
help??  What about diet?? I now find I can eat and drink
things I could not before I went on the Elavil. I have no
constipation but do have more than 3 bowel movements a day -
not really diarrhea but still rather loose. Thank you so
much for your response.
Katie2

[Kevin Pho, MD]

To answer your questions.

1) It has been shown that tricyclic antidepressants such as Elavil can slow transit time and improve symptoms in IBS.  However, it is difficult to say that the symptoms may be totally "cured".  This would be patient-dependent.

2) Studies are limited for the role of probiotics.  To my knowledge, there is no definitive study showing any benenfit for probiotic therapy for the treatment of IBS.

3) Regarding diet, the only proven benefit for IBS would be increasing the fiber in the diet.  Fiber supplements such as Metamucil or Fibercon should be considered.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[TJV]

  May 21, 2003 (Orlando) — Probiotic therapy, primarily in the form of Lactobacillus acidophilus and Bifidobacteria infantis, significantly improves symptoms and quality of life in patients with irritable bowel syndrome (IBS) and other bowel disorders, researchers reported in a number of presentations here at Digestive Disease Week 2003.

In a study designed to assess the efficacy of probiotics alone or in combination with antibiotics in patients with IBS, Stephen M. Faber, MD, from Albemarle Gastroenterology Associates, PC, in Elizabeth City, North Carolina, evaluated treatment in 44 patients with IBS. Twenty patients received probiotics alone and 24 received ciprofloxacin 500 mg twice daily for one week and two probiotic formulations, Lactobacillus (NCFM) 10 billion/g and Bifidobacteia infantis (Bifdo), 10 billion/g for four weeks.

Patients completed the IBS-Quality of Life (IBS-QOL) questionnaire and the Symptom Frequency Index (SFI) before and after treatment. For the study group as a whole, IBS-QOL scores averaged 66.2 before treatment and 84.6 after treatment. SFI scores before treatment averaged 38, decreasing to 18 after treatment.

In patients who received both probiotics and antibiotics, IBS-QOL scores averaged 67.6 before and 87.8 after treatment. SFI scores averaged 35 at baseline, decreasing to 18 after treatment.

In the probiotic-only group, baseline IBS-QOL scores were 69.3, increasing to 86.4 after treatment. SFI scores were 39 at baseline and 17 after treatment.

Differences in IBS-QOL and SFI scores between probiotic plus antibiotic treatment and probiotic-only treatment were statistically insignificant, Dr. Faber reported.

A retrospective look at IBS patients treated with probiotics indicates that there is a deficiency of Lactobacillus in the gut flora in patients with IBS, Dr. Faber noted, "but we're not ready to call IBS an infectious disease."

Probiotic therapy also improved symptoms of ulcerative colitis (UC) in a separate study presented by Richard N. Fedorak, MD, professor of medicine and director of the division of gastroenterology at the University of Alberta in Edmonton, Canada.

In a safety and efficacy study of the probiotic formulation VSL3 (VSL Pharmaceuticals, Inc., Ft. Lauderdale, FL), which contains eight lactic acid bacterial species, Dr. Fedorak and colleagues evaluated 30 patients with active mild-to-moderate UC with recent flares. Patients continued with previous treatment that included mesalamine, corticosteroids, and/or azathiaprine, as long as the treatment regimen was stable prior to the study.

Patients took two VSL3 sachets twice a day for six weeks. Ulcerative Colitis Clinical Scores were measured and sigmoidoscopy performed at baseline and after the six-week treatment period.

Dr. Fedorak reported that remission occurred in 63% (19 patients) and there was a clinical response in an additional 23% (seven patients). There was no response in 13% (four patients). Worsening of symptoms occurred in one patient.

Dr. Fedorak said that probiotic therapy was not associated with any adverse clinical or biochemical events.

"I haven't heard of getting into trouble with probiotics," Dr. Faber told Medscape. "These are organisms that are supposed to be in the gut. The body knows how to control them, so it doesn't seem that you can overtreat."

While probiotics have been recognized as beneficial components of food, Dr. Fedorak pointed out that "we don't use it as a food product anymore but as a treatment.

"Infantile diarrhea can be shortened by about a day from the usual three- to four-day course. That is very important in infants. Probiotics are effective with rotavirus symptoms, with antibiotic-induced diarrhea, in pseudomembranous colitis, and perhaps in radiation-induced diarrhea," he said.

But Dr. Fedorak cautioned that "we don't know how they work. They appear to strengthen the mucosal barrier of the bowel and improve immune function. And we don't know which probiotics to use or in what combination."

DDW 2003: Abstract M1582, presented May 19, 20003; Abstract W1523, presented May 21, 2003.

Reviewed by Gary D. Vogin, MD