Page 99 WHO - Guidelines on the pharmacological treatment of persisting pain in children with medical illness

Risks/benefits
Benefits
Unknown.
Risks
The risk of potentially devastating adverse effects, such as osteonecrosis of the jaw, cannot be discounted.
Uncertainty: yes.

Research agenda
Trials in children concerning the safety and the efficacy of bisphosphonates as adjuvants in the
treatment of bone pain are needed.

A2.2.11 Adjuvants in neuropathic pain: antidepressants

Clinical question
In children with persisting neuropathic pain, what is the evidence for the use of amitryptiline and other
tricyclic antidepressants as compared to selective serotonin reuptake inhibitors in order to achieve rapid,
effective and safe pain control?

Recommendation
At present, it is not possible to make a recommendation for or against the use of tricyclic
antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) as adjuvant medicines in the
treatment of neuropathic pain in children.

Domains and considerations

Quality of evidence
Clinical experience and trial data in adults support the use of tricyclic antidepressants, such as amitriptyline
or nortriptyline and serotonin and norepinephrine reuptake inhibitors, in the treatment of neuropathic
pain (83). There is limited evidence to suggest that the newer SSRIs may be effective for neuropathic pain
treatment in adults (83). There is no evidence for use of antidepressants for the management of pain in
children. There is large clinical experience with the use of amitriptyline for pain management in children.
Uncertainty: yes.

Risks/benefits
Benefits
Unknown.
Risks
The general risks associated with overdose of tricyclic antidepressants are well described. The use
of selective serotonin reuptake inhibitors in children and adolescents with depression has been
associated with an increased risk of suicidal ideation and behaviour, although this risk has not been
evaluated in adequately designed studies to measure suicide as an outcome and to measure whether
SSRIs would modify the risk of suicide completion (84). Fluoxetine has been introduced in the EMLc
for antidepressant disorders in children above 8 years of age.
Uncertainty: yes.

Cost
Amitriptyline is widely available and inexpensive.
Uncertainty: none.

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