Patients with microscopic colitis exhibit, among other symptoms, watery diarrhoea, abdominal pain and weight loss. At the same time, the intestinal mucosa is macroscopically unremarkable. Tissue samples histopathologically show an inflammatory change in the intestinal mucosa. A distinction is made between two subtypes of microscopic colitis: lymphocytic colitis and collagenous colitis. The lymphocytic form is characterised by the presence of lymphocytic infiltrates, while the collagenous form is dominated by a thickened collagenous band beneath the basement membrane of the intestinal mucosa. Various medicinal products have been associated with the onset of microscopic colitis: These include selective serotonin reuptake inhibitors (SSRIs) such as sertraline, serotonin-noradrenaline reuptake inhibitors (SNRIs) such as duloxetine, as well as proton pump inhibitors.
Microscopic colitis associated with sertraline and duloxetine
Incident data |
Description |
|---|---|
Case: 2023 Age: 50 years Sex: Male Medicinal product: Not known Active substances: Sertraline Indication: Not known ADRs: Lymphocytic colitis Outcome: Recovered |
Two weeks after starting sertraline therapy, the patient reported persistent watery diarrhoea with a weight loss of approximately 6 kg. Bacteriological examinations including stool culture were unremarkable. Empirical treatment with an antibiotic was performed but was unsuccessful. After two months of treatment with sertraline, the drug was reduced and then discontinued. Ten days later, his diarrhoea ceased. The diagnosis of lymphocytic colitis was made using colonoscopic biopsies. It is not known whether the patient received any specific treatment for this colitis. |
Case: 2021 Age: 75 years Sex: Male Medicinal product: Cymbalta® Active substances: Duloxetine Indication: Depression ADRs: Microscopic colitis Outcome: Recovering |
One year after starting treatment with duloxetine, the patient reported marked watery diarrhoea (up to ten bowel movements per day) and progressive weight loss. Blood inflammatory markers and thyroid parameters were unremarkable. In the faeces, calprotectin and a test for parasites were negative. Secretory diarrhoea persisted, although an abdomen ultrasound showed no correlate and an initial colonoscopy was unsuccessful. Due to possible drug-induced diarrhoea, the dose of duloxetine was reduced. A second colonoscopy was finally able to detect microscopic colitis. Subsequently, therapy with budesonide was performed and duloxetine was discontinued. This resulted in significant regression of the patient’s symptoms. |
Summary and recommendation
Microscopic colitis is listed as an adverse reaction in the Swiss Information for healthcare professionals for Zoloft® (frequency not known) and Cymbalta® (very rare).
In the literature, the time between the start of treatment and onset of diarrhoea varies between 1 day and 3 months, with a tendency towards a fairly rapid onset, with a median of 4 days (Beaugerie L & Pardi DS, 2005). The time between discontinuation of treatment and cessation of diarrhoea varies between 2 and 30 days (median 5 days).
The exact pathomechanism is not clear. Some authors suggest that, in patients with microscopic colitis, potent serotonergic antidepressants such as SSRIs and duloxetine should be avoided due to their documented association with microscopic colitis and instead recommend mirtazapine or bupropion, which have shown no association (Salter TG and Williams MD, 2017).
Statutory duty of healthcare professionals to report adverse drug reactions (ADRs)
In Switzerland, healthcare professionals who are authorised to dispense or administer medicinal products are obligated to report severe and/or previously unknown side effects. Reports to Swissmedic can be entered and sent in the Electronic Vigilance Reporting Portal “ElViS” (ElViS login).
Supplementary information
Information for healthcare professionals Zoloft
(www.swissmedicinfo.ch)
Information for healthcare professionals Cymbalta
(www.swissmedicinfo.ch)
Beaugerie L, Pardi DS. Review article: drug-induced microscopic colitis - proposal for a scoring system and review of the literature. Aliment Pharmacol Ther. 2005 Aug 15;22(4):277-84
Salter TG, Williams MD. Antidepressant-Associated Microscopic Colitis: A Case Report and Literature Review. Psychosomatics. 2017 May-Jun;58(3):307-312
Reporting adverse drug reactions