Page 135 Acute Pain Management
P. 135






4.3.3 Antidepressant drugs

There
are
no
published
data
on
the
use
of
antidepressants
in
the
management
of
acute

neuropathic
pain,
however
antidepressants
are
effective
in
the
treatment
of
a
variety
of

chronic
neuropathic
pain
states
(Collins,
Moore,
McQuay
&
Wiffen,
2000
Level
I;
Saarto
&
Wiffen,

2007
Level
I;
Sultan
et
al,
2008
Level
I).
When
used
for
the
management
of
pain,
the
onset
of

effect
is
more
rapid
than
when
these
drugs
are
used
to
treat
depression.

8
The
updated
Cochrane
meta‐analysis
(Saarto
&
Wiffen,
2007
Level
I )
looking
at
the
use
of

antidepressant
drugs
in
the
treatment
of
neuropathic
pain
confirmed
the
effectiveness
of

tricyclic
antidepressants
(TCAs)
but
that
there
is
very
limited
evidence
for
the
role
of
selective

serotonin
reuptake
inhibitor
(SSRIs).
This
analysis
also
concluded
that
venlafaxine
appears
to

be
as
effective
as
TCAs,
but
the
result
is
no
longer
significant
as
one
of
the
positive
venlafaxine

studies
has
subsequently
been
retracted.


See
Table
4.1
for
NNTs
and
NNHs.



Table
4.1
 Antidepressants
for
the
treatment
of
neuropathic
pain

Efficacy
 NNT
(95%
CI)

Overall
 


 TCAs
 3.6
(3.0–4.5)


 SSRIs
 
 limited
evidence
of
benefit


 Duloxetine
 5.8
(4.5–8.4)

 CHAPTER
4

Diabetic
neuropathy
 1.3
(1.2–1.5)


Postherpetic
neuralgia
 
 2.7
(2.0–4.1)

HIV‐related
neuropathies
 no
evidence
of
benefit

Minor
adverse
effects
 NNH
(95%
CI)

Pooled
diagnoses
 


 Amitriptyline
 6.0
(4.2–10.7)


 SSRIs
 
 no
dichotomous
data
available

Major
adverse
effects
(withdrawal
from
study)
 NNH
(95%
CI)

Pooled
diagnoses
 


 Amitriptyline
 28.0
(17.6–68.9)


 Duloxetine
 15
(11–25)


 SSRIs
 not
different
from
placebo

Note:
 CI:
confidence
interval;
TCA:
tricyclic
antidepressants;
SSRI:
selective
serotonin
re‐uptake
inhibitors.

Source:
 Adapted
from
Collins,
Moore,
McQuay
&
Wiffen
(2000),
Saarto
&
Wiffen
(2007),
Sultan
et
al
2008 8 


Currently
the
use
of
antidepressants
for
acute
neuropathic
pain
is
mainly
based
on

extrapolation
of
the
above
data.


Amitriptyline
(Kalso
et
al,
1996
Level
II)
but
not
venlafaxine
(Tasmuth
et
al,
2002
Level
II)
was

effective
in
the
treatment
of
neuropathic
pain
following
breast
surgery,
however
the

amitriptyline
side
effects
were
not
well‐tolerated.
Amitriptyline
given
to
patients
with
herpes

zoster
reduced
the
incidence
of
postherpetic
neuralgia
at
6
months
(Bowsher,
1997
Level
II).






































































8

 This
meta‐analysis
includes
a
study
on
venlafaxine
that
has
since
been
withdrawn
from
publication.
Please
refer
to

the
Introduction
at
the
beginning
of
this
document
for
comments
regarding
the
management
of
retracted
articles.

Independent
reanalysis
of
this
meta‐analysis
using
a
random
effects
model
(I2
=
51.3%)
shows
RR
1.87
(95%
CI
0.66–
5.30).
The
results
for
venlafaxine
are
no
longer
significant
and
have
been
excluded
from
Table
4.1.


 Acute
pain
management:
scientific
evidence
 87

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