Antidepressants for pain in rheumatic conditions

[Guest guest]

Antidepressants for pain in rheumatic conditions



Sep 22, 2005



Zosia Chustecka

Paris, France - For the first time, guidelines on the use of

antidepressants in painful rheumatic conditions have been drawn up

and are published online before print in the European Journal of Pain

[1]. The authors, headed by Dr Serge Perrot (Hôpital Cochin-Tarnier,

Paris, France), are from a subgroup of the French Society of

Rheumatology and have a specific interest in rheumatic pain.

Pain is the main symptom of many rheumatic and inflammatory

conditions, and when it cannot be controlled effectively with

analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), or

opioids, additional treatment with an antidepressant may be helpful,

the authors comment. Although the use of antidepressants is

increasing for conditions such as fibromyalgia, rheumatoid arthritis,

spondylarthropathies, and osteoarthritis (OA), there are questions

concerning the use of these drugs. For instance, does the analgesic

effect depend on the antidepressant effect? When is such treatment

appropriate and how long should it be continued?

In an attempt to answer some of these questions, the authors reviewed

the medical literature (from 1996 to 2002) and also drew on expert

opinion within the group. The panel comprised seven rheumatologists,

one psychiatrist, and one neurologist; two of the members were also

pharmacologists. They present the document as " a starting point for

discussion " and designed it to be " flexible enough to gain practical

acceptance in different countries. "

Tricyclics are first choice for analgesia

The analgesic effects of antidepressants have been demonstrated most

convincingly for tricyclic antidepressants (TCAs), such as

amitriptyline, but the evidence is " conflicting " for selective

serotonin reuptake inhibitors (SSRIs), such as fluoxetine, the

authors note. The analgesic effects appear to be independent of the

effect on mood; pain relief is usually observed within one week of

starting treatment, whereas the antidepressant effect usually occurs

after the first two weeks. But side effects are similar whether the

drugs are used to treat pain or depression.

Before initiating treatment with a TCA, the physician should check

for orthostatic hypotension and perform an electrocardiogram, the

group notes. In elderly patients starting TCAs, physicians should

monitor blood pressure, cognition, and intestinal transit. No tests

are necessary before initiation of treatment with an SSRI. Assessment

of treatment efficacy should not be limited to pain evaluation but

should also include functional evaluation, analgesic consumption,

sleep evaluation (quality and duration), and psychological

assessment. These should be started after one week of treatment.

The first choice of antidepressant for pain in patients who are not

depressed is a TCA, initiated at low dose and then increased to the

maximal-tolerated or minimal-effective dose. Antidepressant therapy

should be integrated into a global management program along with

nonpharmacological approaches, the experts write. There is no optimal

duration, but treatment should last for at least four weeks before

being stopped for lack of efficacy. After three to six months of

remission, the dose may be gradually decreased; stopping abruptly may

precipitate side effects (nausea, vomiting, trembling).

Rheumatic conditions

The experts also reviewed the clinical-trial data available for

individual rheumatic conditions and add the following comments:

In fibromyalgia, TCAs are used at doses lower than they are for

depression, probably because of the side effects of these drugs.

Despite their widespread use, TCAs have only a moderate effect, and

only a minority of patients display sustained, marked improvement.

SSRIs are better tolerated but less effective, making it necessary to

increase the dose to obtain significant pain relief.

For chronic low-back pain, tricyclic and tetracyclic antidepressants

appear to moderately reduce symptoms independent of a patient's

depression status. SSRIs do not appear to be beneficial.

In rheumatoid arthritis, amitriptyline, trimipramine, dothiepine, and

paroxetine may have analgesic effects. In ankylosing spondylitis,

amitriptyline may be useful in reducing symptoms. Low doses of

amitriptyline (10-30 mg) may be sufficient to produce an analgesic

effect.

None of the studies included in the review dealt specifically with

OA, but a large study of older patients with arthritis (mostly OA)

and comorbid depression found benefits that extended beyond the

reduction of depressive symptoms and included decreased pain and

improved functional status and quality of life.

The authors conclude that antidepressants are recommended as

analgesics for fibromyalgia, especially TCAs, but they should not be

first-line analgesic treatment in low-back pain, osteoarthritis, or

inflammatory rheumatic painful diseases.

Perrot S, Maheu E, RM, et al. Guidelines for the use of

antidepressants in painful rheumatic conditions. Eur J Pain 2005; DOI:

10.1016/j.ejpain.2005.03.004. Available at: http://

www.sciencedirect.com.



http://www.jointandbone.org/viewArticle.do?primaryKey=566403

[Guest guest]

This was an interesting article. I take two tricyclic antidepressants,

not for depression, but to prevent migraines. They work, too. But maybe

they also help my RA as well. We need all the help we can get, LOL. Sue

On Friday, September 23, 2005, at 08:51 AM, a wrote:

>

> Tricyclics are first choice for analgesia

> The analgesic effects of antidepressants have been demonstrated most

> convincingly for tricyclic antidepressants (TCAs), such as

> amitriptyline, but the evidence is " conflicting " for selective

> serotonin reuptake inhibitors (SSRIs), such as fluoxetine, the

> authors note. The analgesic effects appear to be independent of the

> effect on mood; pain relief is usually observed within one week of

> starting treatment, whereas the antidepressant effect usually occurs

> after the first two weeks. But side effects are similar whether the

> drugs are used to treat pain or depression.

[Guest guest]

This was an interesting article. I take two tricyclic antidepressants,

not for depression, but to prevent migraines. They work, too. But maybe

they also help my RA as well. We need all the help we can get, LOL. Sue

On Friday, September 23, 2005, at 08:51 AM, a wrote:

>

> Tricyclics are first choice for analgesia

> The analgesic effects of antidepressants have been demonstrated most

> convincingly for tricyclic antidepressants (TCAs), such as

> amitriptyline, but the evidence is " conflicting " for selective

> serotonin reuptake inhibitors (SSRIs), such as fluoxetine, the

> authors note. The analgesic effects appear to be independent of the

> effect on mood; pain relief is usually observed within one week of

> starting treatment, whereas the antidepressant effect usually occurs

> after the first two weeks. But side effects are similar whether the

> drugs are used to treat pain or depression.