From the Guidelines
Centrally mediated abdominal pain syndrome (CAPS) should be treated with a multimodal approach, including low-dose tricyclic antidepressants (TCAs) and non-pharmacological interventions, to improve pain management and quality of life. This approach is supported by recent guidelines and studies, such as the 2021 AGA clinical practice update on management of chronic gastrointestinal pain in disorders of gut-brain interaction 1. The treatment of CAPS typically involves a combination of pharmacological and non-pharmacological interventions, including:
- Low-dose tricyclic antidepressants (TCAs) such as amitriptyline, starting at 10-25 mg at bedtime and gradually increasing to 50-100 mg if needed
- Selective serotonin reuptake inhibitors (SSRIs) like sertraline (50-200 mg daily) or serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (30-60 mg daily)
- Non-pharmacological approaches such as cognitive behavioral therapy, relaxation techniques, and hypnotherapy
- Physical therapy and regular exercise to help reduce pain perception
- Patient education and maintaining a regular eating schedule to avoid trigger foods
The British Society of Gastroenterology guidelines on the management of irritable bowel syndrome also support the use of combination gut-brain neuromodulators, such as duloxetine plus gabapentin, for more severe symptoms 1. However, vigilance is required for the development of serotonin syndrome, especially with combinations involving SSRIs and SNRIs. Interventions with reported efficacy for patients with severe or refractory IBS include CBT, integrative group therapy, gut-directed hypnotherapy, and gut-brain therapy 1.
It is essential to prioritize a patient-centered approach, focusing on improving quality of life and reducing pain perception, rather than solely relying on pharmacological interventions. Regular follow-up appointments are necessary to adjust therapy as needed and ensure the best possible outcomes for patients with CAPS.
From the Research
Diagnosis of Centrally Mediated Abdominal Pain Syndrome
- The diagnosis of Centrally Mediated Abdominal Pain Syndrome (CAPS) is still an exclusionary diagnosis, and there are no effective diagnostic biomarkers available yet 2.
- Researchers are exploring the use of serum miRNAs as potential diagnostic biomarkers for CAPS 2.
Treatment of Centrally Mediated Abdominal Pain Syndrome
- Duloxetine is a major pharmacotherapy for CAPS, but some patients do not respond to this treatment 2.
- Pregabalin has shown potential in reducing abdominal pain scores and improving somatic and anxiety symptoms in CAPS patients 3.
- Local analgesic lidocaine and opioid analgesic sufentanil have shown negative efficacy in short-term observation for CAPS treatment 4.
- Behavioral therapies, such as cognitive-behavioral therapy, may be beneficial in managing CAPS, although more research is needed to confirm their efficacy 5.
Pharmacologic Therapy
- Tricyclic antidepressants and selective serotonin reuptake inhibitors may be used to manage abdominal pain in irritable bowel syndrome (IBS), but their efficacy in CAPS is uncertain 6.
- Other pharmacologic therapies, such as antispasmodics, opioid agonists, and bile salt sequestering agents, may be used to manage IBS symptoms, but their efficacy in CAPS is unclear 6.