|
Indian Pediatr 2015;52: 843-844 |
|
Drotaverine for Recurrent Abdominal Pain in
Children
|
Vyom Aggarwal
Division of Pediatric Gastroenterology, Max Hospital,
Pitam Pura, New Delhi, India.
Email:
[email protected]
|
In 1958, Apley described a condition of recurrent
paroxysmal abdominal pain characterized by episodes of abdominal pain in
children 4 to 16 years of age, lasting more than 3 months and affecting
normal activity [1]. The Pediatric Rome II classification has been
proposed to subcategorize chronic abdominal pain based on clinical
presentations namely those with isolated paroxysmal pain, pain with
dyspepsia, pain with altered bowel pattern or abdominal migraine [2,3].
Though it successfully attempts to segregate cases of chronic or
recurrent pains into etiological groups, the functional abdominal pain
(pain in absence of any attributable structural, infectious or
biochemical cause) remains the most common cause in each category. In a
prospective series of 107 children who met Apley’s criteria for
recurrent abdominal pain, Walker, et al. [4] were able to group
only 73% according to the Rome II criteria. The fact that 27% of the
patients could not be classified implies that Rome II classifications
may not be completely helpful to clinicians in guiding therapy that
might be most effective for the presenting symptoms. It needs to be
emphasized that many cases of recurrent abdominal pain remain
undiagnosed or get labeled as functional because of either reluctance on
the part of the pediatrician to investigate further for uncommon
specific causes – like abdominal migraine, acute intermittent porphyria,
lead toxicity, inflammatory bowel disease – or to refer to a
gastroenterologist.
In view of the heterogeneity of recurrent abdominal
pain and the lack of consensus on pathogenesis, it is not surprising
that we lack evidence-based interventions [5]. A systematic review of
pharmacological therapies for recurrent abdominal pain in children
demonstrated some utility of interventions like peppermint oil,
famotidine and pizotifen [6], but the small sample size limits
acceptability of these results [7]. The different modes of action of
these interventions reflect the multiple causation of recurrent
abdominal pain and strengthen the case for targeted approaches to
management.
Drotavarine, a phosphodiesterase–IV inhibitor
non-cholinergic antispasmodic drug, has been used in adults with
irritable bowel syndrome and found to be safe and effective in
amelioration of symptoms, including pain, frequency of loose stools and
constipation [8,9]. In first of its kind pediatric study published in
this issue of Indian Pediatrics, Narang, et al. [10] have
by means of a well-planned and a well-executed double-blind randomized
placebo-controlled trial on a sufficiently large sample, tried to
evaluate efficacy of drotavarine in cases of recurrent abdominal pain.
They have not only been able to demonstrate statistically significant
reduction in frequency of episodes of abdominal pain but also reduction
in school absenteeism and improved parental satisfaction. However,
though it reveals safety and efficacy of the drug during four weeks of
use, it gives no clue if the symptomatic relief is simply because of
continued antispasmodic administration or actual modification of the
disease process. Whether symptoms would recur in the treatment group
upon cessation of therapy is also not elucidated. Certainly, long-term
follow-up of treatment responders is imperative to find the answer.
Another important aspect of the study results is that no statistically
significant difference was observed in the requirement of additional
doses of antispasmodic drugs in treatment and placebo groups. This
limits the prospect of relying on drotaverine as a sole therapeutic
agent and questions its utility in routine use. The authors have used a
standard dose of 20 mg per dose in children aged 4 to 6 years and 40 mg
per dose in children above 6 years, irrespective of weight or surface
area. While such dose recommendation may be acceptable for use on
as-and-when-required basis, the optimal dose needs to be worked out on
the basis of weight, if the drug is intended to be used for as long
period as four weeks. Children, unlike adults, have been shown to
outgrow from functional pain. It is also well documented that pain often
subsides after 2 to 6 weeks of diagnosis, perhaps implying that if a
positive diagnosis of functional pain is provided, parents and children
accept non organic nature of the disease [11]. Therefore, the reduction
of symptoms by any particular medicine may not directly indicate
efficacy of the agent. Many cases of abdominal pain are thought to be
due to minor or self-limiting illnesses and providing symptomatic relief
for some duration (optimal period may vary in different conditions and
remains yet to be defined) may be all that is required [12]. Drotaverine
may be a safe and somewhat effective agent for particularly this type of
patients, but it may be little too early to recommend its routine use in
children with recurrent abdominal pain. As of now, the principal use of
drotaverine in recurrent abdominal pain seems to be in carefully
selected cases with aim to alleviate symptoms and reduce school
absenteeism, till a definitive etiology is worked out or specific
management plan is instituted.
Funding: None; Competing interests: None
stated.
References
1. Apley J, Naish N. Recurrent abdominal pains. A
field survey of 1000 school children. Arch Dis Child. 1958;33:165-70.
2. Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher
DR, Hyams JS, Milla PJ, et al. Childhood functional
gastrointestinal disorders. Gut. 1999;45 (suppl 2):1160-8.
3. Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E,
Hyams JS, Staiano A, et al. Childhood functional gastrointestinal
disorders: child/adolescent. Gastroenterology. 2006; 130: 1527-37.
4. Walker LS, Lipani TA, Greene JW, Caines K, Stutts
J, Polk DB, et al. Recurrent abdominal pain: symptom subtypes
based on the Rome II criteria for pediatric functional gastrointestinal
disorders. J Pediatr Gastroenterol Nutr. 2004;38:187-91.
5. Plunkett A, Beattie RM. Recurrent abdominal pain
in childhood. J R Soc Med. 2005;98:101-6.
6. Weydert JA, Ball TM, Davis MF. Systematic review
of treatments for recurrent abdominal pain. Pediatrics. 2003;111:e1-11
7. American Academy of Pediatrics Subcommittee on
Chronic Abdominal Pain; North American Society for Pediatric
Gastroenterology Hepatology, and Nutrition. Chronic abdominal pain in
children. Pediatrics. 2005;115:e370-81
8. Rai RR, Dwivedi M, Kumar N. Efficacy and safety of
drotaverine hydrochloride in irritable bowel syndrome: A randomized
double-blind placebo-controlled study. Saudi J Gastroenterol.
2014;20:378-82.
9. Misra SC, Pande R. Efficacy of drotaverine in
irritable bowel syndrome: A double blind randomized, placebo controlled
clinical trial. Am J Gastroenterol. 2000; 95:2544.
10. Narang M, Shah D, Akhtar H. Efficacy and safety
of drotaverine hydrochloride in children with recurrent abdominal pain:
A randomized placebo controlled trial. Indian Pediatr. 2015;52:847-51.
11. Crushell E, Rowland M, Doherty M, Gormally S,
Harty S, Bourke B, et al. Importance of parental conceptual model
of illness in severe recurrent abdominal pain. Pediatrics.
2003;112:1368-72.
12. Edwards MC, Mullins LL, Johnson J, Bernardy N.
Survey of pediatricians’ management practices for recurrent abdominal
pain. J Pediatr Psychol. 1994;19:241-53.
|
|
|
|