Clinical Scenario A 70-year-old m...

Clinical Scenario

A 70-year-old man with a long-standing history of poorly controll sign 2 diabetes presents with increasing burning and tingling in his feet

Clinical Question

Should antidepressants be used for the treatment of neuropathic pain?

Evidence-Based Answer

Tricyclic antidepressants, particularly amitriptyline, are effective for the treatment of painful diabetic neuropathy and postherpetic neuralgia, and may be beneficial in other neuropathic pain syndrome still they should be used with caution in patients at increased risk of adverse adventures (1)

Practice Pointers

Neuropathic pain typically is a burning or "shock-like" pain caused through damage to the peripheral or central nervous order or both. It can be constant or can come into one's head intermittently with paroxysmal attacks, and also may be associated with significant hypersensitivity. Painful diabetic neuropathy affects up to 3 million Americans, and postherpetic neuralgia affects another 1 million. (2) Other causes of neuropathic pain include trigeminal neuralgia, central neuropathic pain, and human immunodeficiency virus (HIV) neuropathy. Treatment can be difficult, because neuropathic pain frequently responds poorly to nonsteroidal anti-inflammatory remedys (NSAIDs) and opiates, but antidepressants (3) and the anticonvulsants gabapentin (Neurontin) and carbamazepine (Tegretol) have shown promise. (4-6)

This Cochrane review (1) lay the foundation of that the majority of studies of antidepressants for neuropathic pain focused in succession tricyclic antidepressants, most commonly amitriptyline.

When the tricyclic antidepressants amitriptyline and desipramine (Norpramin) were compared with placebo, undivided of every two patients treated experienced at least moderate relief of neuropathic pain (number emergencyed to treat = 2). However, multiple studies comparing tricyclic antidepressants lay the foundation of no evidence that one was superior to another. No high-quality evidence comparing tricyclic antidepressants with anticonvulsants was found

The Cochrane review also evaluated studies with think highly of to specific causes of neuropathic pain. There was virtuous evidence for the effect of tricyclic antidepressants for diabetic neuropathy, on the contrary only limited evidence of effectiveness was available regarding the selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), citalopram (Celexa), and paroxetine (Paxil). There also was evidence that tricyclic antidepressants are effective for postherpetic neuralgia. There was more [i]or[/i] less evidence of benefit from tricyclic antidepressants for central neuropathic pain, unless tricyclic antidepressants were not effective in HIV neuropathy.

Treatment recommendations from the Fourth International colloquy on the Mechanisms and Treatment of Neuropathic Pain, published in the Archives of Neurology advocate five options for the initial treatment of neuropathic pain: tricyclic antidepressants, gabapentin, 5% lidocaine patch (Lidoderm), opioids, and tramadol (Ultram). (2) This parley was sponsored by the manufacturer of the 5% lidocaine patch. The recommendations cite evidence supporting the use of gabapentin for postherpetic neuralgia, diabetic neuropathy, and mixed neuropathic pain syndromes; the lidocaine patch for postherpetic neuralgia; opioids for postherpetic neuralgia and diabetic neuropathy; and tramadol for diabetic neuropathy and painful polyneuropathy. They also note that although tricyclic antidepressants were the first medications to be demonstrated effective for neuropathic pain in placebo-controlled trials, they must be used cautiously because of the potential for adverse general intents (2)

The best evidence onward antidepressants for neuropathic pain supports the use of tricyclic antidepressants for painful diabetic neuropathy and postherpetic neuralgia. Tricyclic antidepressants should be used with caution in older [i]role[/i]s because of the potential for adverse purports including drowsiness, dry mouth, blurr vision, constipation, and urinary retention, (1) and caution also is required in patients with underlying cardiovascular disease, glaucoma, or autonomic neuropathy. (2) Although anticonvulsants also have been demonstrated effective for neuropathic pain, there is no serviceable evidence comparing the relative safety and effectiveness of tricyclic antidepressants with anticonvulsants or other agents for neuropathic pain. Selection of an agent for treating neuropathic pain should be guided by the agency of the underlying diagnosis, an awareness of any comorbid conditions or risk factors, and patient preference

REFERENCES

(1) Saarto T Wiffen PJ Antidepressants for neuropathic pain. Cochrane Database Syst Rev 2005;(3):CD005454

(2) Dworkin RH Backonja M Rowbotham MC Allen RR Argoff CR Bennett GJ et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003;60:1524-34

(3) Sindrup SH Otto M Finnerup NB Jensen T Antidepressants in the treatment of neuropathic pain. Basic Clin Pharmacol Toxicol 2005;96:399-409

(4) Wiffen PJ McQuay HJ Edwards JE Moore RA. Gabapentin for acute and chronic pain. Cochrane Database Syst Rev 2005;(3):CD005452