GUIDELINE - Antidepressants for pain in rheumatic conditions

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Antidepressants for pain in rheumatic conditions

Rheumawire

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.

Source

1. 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

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