Question: I have bad stomach pain after taking a drug for a bladder condition. I was also on Prozac, Elavil and Lorazepam at the time, for bladder and depression issues. I stopped the Prozac because I wanted to take less drugs, because now I also have to take Prevacid. So, currently I am taking Prevacid, Lorazepam, and Elavil (lowest dose of each) Would cymbalta work for me for the stomach pain? The doctors are calling it nonulcer dyspepsia.

Answer: I’m not clear about whether you are still on a med for a bladder condition, but I’m presuming not. Meds that effect the bladder usually also have some effects on the stomach. I’m guessing that the bladder condition is interstitial cystitis, but there are several other possibilities.

Prozac can result in stomach spasms and pain, either when first starting it or when going off. Tapering Prozac more slowly would help if that was the case. Starting it back would initially help and then tapering at 1-2/week would be less likely to cause problems. Cymbalta has been found to help with pain of various types, but Elavil also helps by similar mechanisms. Increasing the dose of Elavil should be tried before adding Cymbalta, which shouldn’t be mixed with Elavil (i.e., Elavil would best be tapered off before adding Cymbalta).

Make sure you find out what was causing the stomach pain. Sometimes the cause remains unclear in which case you need to monitor any possible related symptoms or changes and be periodically reevaluated.

In long term management of Irritable Bowel Syndrome (IBS), diet is more important than medication. You need adequate fiber to maintain a soft, formed, moist, preferably daily bowel movement. Inadequate bowel motility causes constipated stool that irritates the bowel wall and causes colon spasms. Eating too large a meal (especially a fatty meal) causes spasms of the colon via the gastro colic reflex. Some people are intolerant of certain foods - milk products, wheat, and lettuce are common examples. Of course, good sleep, physical fitness and general stress management are essential to the management of IBS.
Muscle in the intestine is controlled by the autonomic nervous system and therefore doesn’t respond to the same relaxants as skeletal muscle. Some antidepressants - Paxil of the SSRI’s and the tricyclics have relaxation of the intestines as a potential side effect by blocking the parasympathetic system. Paxil may help IBS with predominantly diarrhea. Zoloft is more stimulating to the intestine and might help IBS with constipation. Medications that increase norepinephrine (Effexor, Cymbalta, and Wellbutrin) can also decrease intestinal bowel activity by activating the sympathetic nervous system. Both of these effects can decrease the spasms associated with IBS.
Intestinal muscle is especially sensitive to serotonin and medications that block a certain serotonin receptor (5HT3) are strong intestinal wall relaxants (Lotrinex and Zofran). Conversely IBS with predominantly constipation responds to the more recently available stimulant of a particular serotonin receptor (5HT4) called Zelnorm. Opiods Lomotil (Imodium) at the milder level, and Paregoric at the strongest level are powerful relaxants that are sometimes used for severe spasms of the colon. Anticholinergics (especially Levsin) work better for stomach spasms but have some relaxant effects for spasms of the colon. Levsin has the advantage of coming in a quickly acting sublingual (under the tongue) tablet.
Benzodiazepines that reduce general arousal and anxiety have an indirect effect on gastrointestinal muscle. The only one that may have more direct relaxant effect would be Klonopin (clonazepam) since it is the one that decreases serotonin release. Xanax is better for depression. Klonopin is best for obsessing and especially racing thoughts.

Metabolic Syndrome was the headline issue at last week’s annual meeting of psychiatrists (APA). What is it? Do you fit the criteria? What can you do about it? What Is It? Metabolic Syndrome is common and it increases your risk of dying from a heart attack by 3 1/2 times. If you or a loved one meet the criteria you can do something about it. I’m sure I have been embarrassing people lately when I whip out my tape measure and measure their waist - at the level of the umbilicus. It turns out that abdominal fat is much more of a health problem (the apples) as opposed to hips and butt fat (pears) which has no increased heart risk. In fact, recently the big "booty" has been in fashion. But a waistline of 35" or more in women or 40" or more in men is one of the 5 criteria for Metabolic Syndrome. (If you have any 3 of the 5 criteria you get the diagnosis). The 2nd factor is increased blood pressure and the standard now is tougher, 130/80. If either systolic is >130 or diastolic is >80 you have elevated blood pressure. The other 3 criteria require a fasting blood test (8 hours with nothing but water). Fasting blood sugar should be 100 or less. Triglycerides should be less than 150 and good cholesterol (HDL) should be 40 or more in men and 50 or more in women. These tests are simple and inexpensive and everyone should know where they stand. A family history of any of these problems increases your risk. Metabolic Syndrome and Psychiatry Why are psychiatrists taking a lead role in expanding public awareness? It turns out that some of the medications we commonly use can increase the risk of any or all of these factors. Three commonly used antidepressants used long term can cause weight gain. Some antidepressants can increase blood pressure but most striking is the group of mood stabilizers called Atypicals. Some of these medications can seriously increase risk of weight gain, increase fasting sugar, increase triglycerides and increase bad cholesterol. A consensus panel including members from the American Psychiatric Association and Endocrinologists convened in November of 2004. They concluded that the medications Clozaril and Zyprexa have a significant risk of causing Metabolic Syndrome. Seroquel and Risperdal have a lesser risk and Geodon and Abilify have the lowest risk. But the FDA is cautioning doctors to screen for these problems and to monitor patients that are on any of the medications from this category. Doctors consider the benefits vs. risks of all the medications that we prescribe. Ironically the "Atypicals" are among our most useful medications. At higher doses they treat the most severe symptoms of mania and schizophrenia, but they are also used for refractory depression and anxiety disorders, including hair pulling and skin picking. In fact, they are the most versatile of any group of medications used for stress disorders. Although we can’t say with absolute certainty that some of these medications are a lot safer than others, the consensus panel and clinical experience strongly suggest that this is the case. It will take large comparison studies to prove it. What Can You Do About Metabolic Syndrome? If you meet criteria for Metabolic Syndrome and you are on one or more of these medications you shouldn’t just stop them. You may want to consider changing if you are on the higher risk medications. Or you may discuss with your physician some of the behavioral and medical options to help reduce your risk. Of course the main cause for the Metabolic Syndrome is our fast food, sedentary life style. Dieting is not the answer - I will address that issue in my next article. Heart disease is by far the most common cause of premature death in men and women. Even if it doesn’t kill you it will lower your quality of life. Don’t wait for your doctor to pull out his blood pressure cuff and measuring tape. Be proactive! Take action now to find out where you stand on all 5 criteria.

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Metabolic Syndrome Criteria (If you answer “yes” to 3 or more of these questions you could be diagnosed with Metabolic Syndrome.) 1. Is your waistline 35" or more (for women) or 40" or more (for men)? (Measured at the belly button, not under the gut!) 2. Is your blood pressure above 130/80? (either systolic is >130 or diastolic is >80) 3. Is your fasting blood sugar above 100? 4. Are your triglycerides above 150? 5. Is your HDL cholesterol less than 40 (for men) or 50 (for women)?