La place des antidépresseurs dans le syndrome du côlon irritable : Le point sur la littérature

Irritable bowel syndrome is one of the most common gastrointestinal disorders, characterized by recurrent abdominal pain and bowel movement disturbances (constipation, diarrhea, or both). It is estimated to affect about 10% of the general population, with highly variable prevalence rates. Given the multifactorial etiology of irritable bowel syndrome, psychological factors are believed to play an important role. Centrally acting drugs such as antidepressants may be effective in treating patients with irritable bowel syndrome. While the effectiveness of psychological therapies in irritable bowel syndrome remains debated, pharmacological treatment with antidepressants could represent a reasonable therapeutic alternative. In this update, we will discuss the comorbidity and possible links between depression and irritable bowel syndrome, as well as the role and effectiveness of antidepressants in the pharmacological treatment of irritable bowel syndrome. Patients with irritable bowel syndrome often suffer from psychological comorbidities, such as anxiety and depression. Several meta-analyses and systematic reviews have shown that these patients exhibit high levels of anxiety and depression. However, it is unclear whether the high rate of depression and/or anxiety in irritable bowel syndrome patients is part of the disease's pathophysiology or a direct result of its chronic and recurrent nature. Alterations in the gut–brain axis, the gut microbiota, and the neuro-immune system could be the cornerstone of the association between irritable bowel syndrome and depression. Both conditions are associated with dysfunction of the autonomic nervous system. Indeed, several pathways connect the gut microbiota to the brain; the parasympathetic system, through the vagus nerve, can modulate intestinal peristalsis, which in turn can affect the microbiota. Antidepressants can be useful in functional gastrointestinal disorders, such as irritable bowel syndrome, not only because of their effects on the central nervous system but also due to their peripheral effects on pain perception, visceral hypersensitivity, and gastrointestinal motility. Antidepressants target the hypothalamic–pituitary–adrenal axis and influence the autonomic nervous system, in addition to their anti-inflammatory and analgesic properties. These peripheral and central effects may make them effective treatments for irritable bowel syndrome symptoms. Treatment of irritable bowel syndrome is currently symptomatic, and there is no single medication, combination of medications or universal treatment plan for all patients. Antidepressants are commonly used and recommended in guidelines for the treatment of this syndrome. The best studied antidepressants in this indication are tricyclics and selective serotonin reuptake inhibitors, the former being the most effective and the latter the best tolerated. The most commonly studied tricyclics are amitriptyline, desipramine, doxepin, and nortriptyline. Among selective serotonin reuptake inhibitors, the most frequently studied drugs are citalopram, fluoxetine, and paroxetine. On the other hand, there have been no trials of serotonin and norepinephrine reuptake inhibitors in irritable bowel syndrome. Studies on the use of antidepressants in irritable Bowel Syndrome have focused more on efficacy rather than on the tolerance and side effects of these substances. However, the lack of sufficient data is not a real obstacle to their prescription for this indication, as the side effect profile of antidepressants has been well established for many years. Overall, available literature data support the use and efficacy of antidepressants for the treatment of irritable bowel syndrome, which may be an alternative therapy for patients with this syndrome.