Pregabalin Is First Drug Approved for Fibromyalgia

Total Page:16

File Type:pdf, Size:1020Kb

Pregabalin Is First Drug Approved for Fibromyalgia 50 Pain Medicine C LINICAL P SYCHIATRY N EWS • August 2007 Pregabalin Is First Drug Approved for Fibromyalgia BY ELIZABETH MECHCATIE that are not usually painful, and that pre- cording to the revised prescribing infor- The daily dose should be administered Senior Writer gabalin may reduce the degree of pain ex- mation for pregabalin. The two studies— in two divided doses per day, starting at a perienced by patients with fibromyalgia by a 14-week double-blind placebo-controlled total daily dose of 150 mg/day, which regabalin has become the first drug binding to a specific protein within study and a 6-month randomized with- may be increased to 300 mg/day, within 1 to win approval by the Food and “overexcited nerve cells.” drawal study—found that treatment was week; the maximum dose is 450 mg/day, PDrug Administration for the man- The approval “marks an important ad- associated with a reduction in pain by vi- according to the prescribing information. agement of fibromyalgia. vance, and provides a reason for optimism sual analog scale and improvements based The most common side effects in the tri- The FDA based the approval on two for the many patients on a patient global as- als were mild to moderate dizziness and double-blind, controlled trials of approxi- who will receive pain Side effects such as sessment and on the sleepiness, blurred vision, weight gain, dry mately 1,800 patients. Data from the stud- relief ” with prega- Fibromyalgia Impact mouth, and swelling of the hands and feet ies have shown that patients with fi- balin, Dr. Steven Gal- dizziness and sleepiness, Questionnaire. also were also reported. Side effects ap- bromyalgia “have decreased pain after son, the director of blurred vision, weight gain, In the 14-week peared to be dose related, according to the taking [pregabalin], but, the mechanism the FDA’s Center for study, some patients FDA. Patients should talk to their physi- by which [pregabalin] produces such an ef- Drug Evaluation and dry mouth, and swelling of experienced reduc- cians or other health care providers about fect is unknown,” according to an agency- Research said in the the hands and feet seemed tions in pain during whether pregabalin—which can impair issued statement. FDA statement. He the first week of motor function, concentration, and atten- In the clinical trials of patients with fi- added, however, that to be dose related. treatment, which tion—can affect their ability to drive, the bromyalgia, those on pregabalin (Lyrica) consumers should continued through- FDA advised. Pfizer has agreed to conduct had “rapid and sustained improvements in understand that some patients in trials out the study. Nearly 70% of those on a a study of pregabalin in children and an- pain,” compared with those on placebo, did not benefit from the drug, and that total daily dose of 300 mg of pregabalin, other in women who are breast-feeding. and “reported feeling better and improve- “we still have more progress to make for and 78% of those on a total daily dose of Pregabalin, a centrally acting drug, was ments in physical function,” according to treatment of this disorder.” 450 mg experienced any improvement on first approved in 2004 for the manage- a statement issued by Pfizer, which man- The two studies enrolled patients diag- the patient global impression of change ment of neuropathic pain associated with ufactures pregabalin. The same statement nosed with fibromyalgia using American scale, compared with 48% of those on diabetic peripheral neuropathy and post- explains that the drug’s mechanism of ac- College of Rheumatology (ACR) criteria, placebo. The total daily dose of 600 mg herpetic neuralgia, and for the adjunctive tion for fibromyalgia is not known, but which are a history of widespread pain for was not more effective than the lower dos- therapy for adult patients with partial states that patients with fibromyalgia may 3 months and pain present at 11 or more es, and there was evidence of dose-relat- onset seizures. It is taken orally in capsule be more sensitive than normal to stimuli of the 18 specific tender point sites, ac- ed side effects. form. ■ Migraine Patients May Benefit Look for Depression, PTSD in From Magnesium or CoQ10 Iraq War Vets With Migraines BY LESLIE SABBAGH The most important sup- Dr. Mauskop recommends BY MARY JO M. DALES diers’ return, indicated that nearly Contributing Writer plement, according to Dr. a combination of magne- Editorial Director 20% had migraine headaches. Mauskop, is magnesium. “It’s sium, feverfew, and riboflavin: The study results are limited by R ANCHO M IRAGE, known that up to 50% of “I find that about half of peo- B OSTON — In soldiers returning their self-reported nature, which does C ALIF. — Alternative ther- people with acute migraine ple are very happy with [this from combat in Iraq, a self-reported not establish a diagnosis and is likely apies are not a replacement have a magnesium deficien- combination]. Sometimes history of migraine headaches was as- to result in more reports of symp- for prescription drugs in mi- cy. ... It is much more effec- their headaches completely sociated with at least twice the risk of toms; they also are limited by a lack graine treatment, but they tive to treat them with a disappear so that they don’t symptoms of depression, posttrau- of information about predeployment can reduce the severity of the product they’re deficient in need prescription drugs.” matic stress disorder, and anxiety as rates of migraine. Nevertheless, the attacks and help ease symp- rather than using drugs,” he The triple combination, was seen in similar soldiers without rates are twice those seen in 20- to 40- toms, reported Dr. Alexander said. Magnesium is “very ef- available as MigreLief, costs migraines, based on a study present- year-olds in the general population Mauskop. fective for 50% of those who $18 per month, and “if mon- ed at the annual meeting of the Amer- and in men, who comprised 96% of In fact, “anyone suffering are deficient in it, but even ey is not an issue, I add ican Academy of Neurology. the study participants. from migraines can benefit prescription drugs work for CoQ10.” Patients take 300 Migraines appear to be frequently Respondents answered 15 questions from these treatments,” Dr. only 50% of migraineurs” mg/day of MigreLief for 8 associated with symptoms of psychi- about the nature and frequency of Mauskop said. The most im- (Headache 2003;43:601-10). weeks. Although one study atric conditions in soldiers returning any headaches in the last 3 months. portant point, he stressed at a Research has found that, that showed favorable results from deployment, Maj. Jay C. Erick- They also completed the four-ques- meeting sponsored by the Di- for migraine, CoQ10 at 300 in migraine patients used 100 son, MC, USA, said during a press tion Primary Care PTSD Screen (PC- amond Headache Clinic, is mg/day is effective, and that mg t.i.d., “I often recom- conference at the meeting, where the PTSD) and the Patient Health Ques- that nonpharmacologic for Parkinson’s disease 1,200 mend 300 mg once daily due study results were presented during a tionnaire (PHQ9) screen for methods can be as effective as mg/day is effective. “Ri- to adherence issues.” scientific poster session. depression and anxiety. drugs, if not more effective. boflavin has similar function Patients have a continuum Although all soldiers returning The responses indicated that 32% When instituting an alterna- in the body as CoQ10 and of responses. “Some say their from deployment undergo mental screened positive for depression, 22% tive approach, the first step is was shown to prevent mi- headaches are more respon- health screening, there is the possi- for PTSD, and 9% for anxiety. Over- to eliminate food triggers, en- graine in one double-blind sive to prescription drugs and bility that headaches and symptoms all, 39% of respondents had at least courage a proper sleep regi- study. Although the thera- some have total disappear- of a psychiatric condition could pre- one psychiatric condition. Respon- men, regular meal intake, and peutic amount of riboflavin ance of migraines, with most sent after such testing and possibly dents with migraines, compared with sufficient hydration. is very high—400 mg/day; responses somewhere in the outside the Veterans Affairs health those without migraines, had much Actual alternative thera- many multivitamins have middle,” he said. care system, he said. Mental health higher rates of depression symptoms pies to control physiologic only 2-3 mg,” he said (Neu- Butterbur has only one screening is warranted to assure that (50% vs. 27%), symptoms of PTSD response to stress include rology 1996;50:440-66). manufacturer, Dr. Mauskop psychiatric disorders are identified (39% vs. 18%), and anxiety symptoms regular aerobic exercise and Butterbur, 50 mg t.i.d, has said, “but feverfew is sold by and properly treated at that time. (17% vs. 7%). biofeedback, said Dr. also been found to help treat many companies and the Dr. Erickson of Madigan Army Migraine days per month were Mauskop, director of the migraine, most likely due to products are not always of Medical Center at Fort Lewis in Taco- linked to a higher probability of a pos- New York Headache Center. its anti-inflammatory prop- good quality. Patients need ma, Wash., reported the findings from itive screen for depression and PTSD, For migraines, the most erties, or “maybe something to buy recognized brands or a health screening questionnaire com- but not a higher rate of anxiety symp- commonly used supplements else. Herbal products contain the triple combination sup- pleted by nearly 2,200 of 3,600 soldiers toms.
Recommended publications
  • Intravenous Ketamine Alleviates Pain in a Rheumatoid Arthritis Patient with Comorbid Fibromyalgia
    Case Report J Med Cases. 2018;9(5):142-144 Intravenous Ketamine Alleviates Pain in a Rheumatoid Arthritis Patient With Comorbid Fibromyalgia Ashraf F. Hannaa, b, Bishoy Abrahama, Andrew Hannaa, Micheal McKennaa, Adam J. Smitha Abstract bance, and psychological distress [4]. It is commonly regarded as the “prototypical central sensitivity syndrome” [5]. While A 49-year-old woman with rheumatoid arthritis (RA) and comorbid its etiology is not fully understood, fibromyalgia is thought to fibromyalgia presented to the clinic in extreme pain, described to be result from abnormal central pain processing and increased a 10 on an 11-point pain intensity numerical rating scale (PI-NRS). central sensitivity that results in intense, widespread pain. Fi- Because the patient also met the diagnostic criteria for fibromyalgia bromyalgia is diagnosed using the 2010 American College of and conventional medications did not achieve adequate pain control Rheumatology (ACR) criteria [6]: 1) Widespread pain index for either condition, the off-label use of intravenous (IV) ketamine (WPI) ≥ 7 and symptom severity (SS) scale score ≥ 5 or WPI was presented as an alternative therapeutic option. The patient un- 3 - 6 and SS scale score ≥ 9. 2) Symptoms have been present derwent 10 consecutive IV infusion sessions with increasing doses at a similar level for at least 3 months. 3) The patient does not of ketamine hydrochloride without any complications. Following the have a disorder that would otherwise explain the pain. 10th infusion, the patient reported that her pain was virtually non- A recent epidemiological study characterized the preva- existent (PI-NRS 0 - 1). lence of fibromyalgia among patients without pain, with re- gional pain, and with widespread pain [4].
    [Show full text]
  • Ketamine for Chronic Non- Cancer Pain: a Review of Clinical Effectiveness, Cost- Effectiveness, And
    CADTH RAPID RESPONSE REPORT: SUMMARY WITH CRITICAL APPRAISAL Ketamine for Chronic Non- Cancer Pain: A Review of Clinical Effectiveness, Cost- Effectiveness, and Guidelines Service Line: Rapid Response Service Version: 1.0 Publication Date: May 28, 2020 Report Length: 28 Pages Authors: Khai Tran, Suzanne McCormack Cite As: Ketamine for Chronic Non-Cancer Pain: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines. Ottawa: CADTH; 2020 May. (CADTH rapid response report: summary with critical appraisal) ISSN: 1922-8147 (online) Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services. While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document.
    [Show full text]
  • Pubmed/19078481?Dopt=Abstract
    Efficacy of tramadol in treatment of pain in fibromyalgia. - Pu... https://www.ncbi.nlm.nih.gov/pubmed/19078481?dopt=Abstract PubMed Format: Abstract J Clin Rheumatol. 2000 Oct;6(5):250-7. Efficacy of tramadol in treatment of pain in fibromyalgia. Russell IJ1, Kamin M, Bennett RM, Schnitzer TJ, Green JA, Katz WA. Author information Abstract An outpatient, randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy and safety of tramadol in the treatment of the pain of fibromyalgia syndrome. One hundred patients with fibromyalgia syndrome, (1990 American College of Rheumatology criteria), were enrolled into an open-label phase and treated with tramadol 50-400 mg/day. Patients who tolerated tramadol and perceived benefit were randomized to treatment with tramadol or placebo in the double-blind phase. The primary efficacy outcome measurement was the time (days) to exit from the double-blind phase because of inadequate pain relief, which was reported as the cumulative probability of discontinuing treatment because of inadequate pain relief. One hundred patients entered the open-label phase; 69% tolerated and achieved benefit with tramadol. These patients were then randomized to continue tramadol (n = 35) or convert to a placebo (n = 34) during a 6-week, double-blind treatment period. The Kaplan-Meier estimate of cumulative probability of discontinuing the double blind period because of inadequate pain relief was significantly lower in the tramadol group compared with the placebo group (p = 0.001). Twenty (57.1%) patients in the tramadol group successfully completed the entire double-blind phase compared with nine (27%) in the placebo group (p = .015).
    [Show full text]
  • Therapeutic Class Overview Neuropathic Pain and Fibromyalgia Agents
    Therapeutic Class Overview Neuropathic Pain and Fibromyalgia Agents INTRODUCTION • Neuropathic pain is commonly described by patients as burning or electrical in nature and results from injury or damage to the nervous system (Herndon et al 2017). Management of neuropathic pain may prove challenging due to unpredictable patient response to drug therapy (Attal et al 2010). • Fibromyalgia is characterized by chronic musculoskeletal pain with unknown etiology and pathophysiology. Patients typically complain of widespread musculoskeletal pain, fatigue, cognitive disturbance, psychiatric symptoms, and multiple somatic symptoms (Goldenberg 2019). Fibromyalgia is often difficult to treat and requires a multidisciplinary, individualized treatment program (Goldenberg 2018). • This review focuses on medications that are approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia, neuropathic pain, and/or post-herpetic neuralgia (PHN). The products in this review include Cymbalta (duloxetine), Gralise (gabapentin ER), Horizant (gabapentin enacarbil ER), Lidoderm (lidocaine 5% patch), Lyrica (pregabalin), Lyrica CR (pregabalin ER), Neurontin (gabapentin), Nucynta ER (tapentadol ER), Qutenza (capsaicin), Savella (milnacipran), and ZTlido (lidocaine 1.8% topical system). These agents represent a variety of pharmacologic classes, including anticonvulsants, serotonin-norepinephrine reuptake inhibitors (SNRIs), extended-release (ER) opioids, and topical analgesics. As such, these agents hold additional FDA-approved indications
    [Show full text]
  • Corporate Medical Policy Nerve Fiber Density Testing AHS – M2112 “Notification”
    Corporate Medical Policy Nerve Fiber Density Testing AHS – M2112 “Notification” File Name: nerve_fiber_density_testing Origination: 01/01/2019 Last CAP Review: n/a Next CAP Review: 01/01/2020 Last Review: 01/01/2019 Policy Effective April 1, 2019 Description of Procedure or Service Nerve fiber density testing involves analysis of skin biopsy stained with an antibody to antiprotein gene product 9.5 (Wilkinson et al., 1989) which avidly stains all axons (Dalsgaard, Rydh, & Haegerstrand, 1989). The number and morphology of axons within the epidermis are evaluated to determine epidermal nerve fiber density (McCarthy et al., 1995) and assess for the presence and degree of neuropathy (A. G. Smith & Gibson, 2018). ***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Policy BCBSNC will provide coverage for nerve fiber density testing when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Benefits Application This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. When nerve fiber density testing is covered Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small-fiber neuropathy
    [Show full text]
  • Fibromyalgia
    Fibromyalgia SANGITA CHAKRABARTY, MD, MSPH, Meharry Medical College, Nashville, Tennessee ROGER ZOOROB, MD, MPH, Meharry Medical College and Vanderbilt University, Nashville, Tennessee Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid con- ditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective. (Am Fam Physician 2007;76:247-54. Copyright © 2007 American Academy of Family Physicians.) This article exemplifies ibromyalgia is an idiopathic, chronic, gesting the contribution of both genetic and the AAFP 2007 Annual nonarticular pain syndrome defined environmental factors.4 Clinical Focus on manage- ment of chronic illness. by widespread musculoskeletal Demographic and social characteristics ▲ pain and generalized tender points associated with the presence of fibromyalgia See editorial on F(Table 1). Other common symptoms include are female sex, being divorced, failing to com- page 290. ▲ sleep disturbances, fatigue, headache, morning plete high school, and low income. Psycho- Patient information: Handouts on fibromyalgia stiffness, paresthesias, and anxiety.
    [Show full text]
  • The Journal of Rheumatology Volume 75, No. Is Fibromyalgia a Neuropathic Pain Syndrome?
    The Journal of Rheumatology Volume 75, no. Is fibromyalgia a neuropathic pain syndrome? Michael C Rowbotham J Rheumatol 2005;75;38-40 http://www.jrheum.org/content/75/38 1. Sign up for TOCs and other alerts http://www.jrheum.org/alerts 2. Information on Subscriptions http://jrheum.com/faq 3. Information on permissions/orders of reprints http://jrheum.com/reprints_permissions The Journal of Rheumatology is a monthly international serial edited by Earl D. Silverman featuring research articles on clinical subjects from scientists working in rheumatology and related fields. Downloaded from www.jrheum.org on September 24, 2021 - Published by The Journal of Rheumatology Is Fibromyalgia a Neuropathic Pain Syndrome? MICHAEL C. ROWBOTHAM ABSTRACT. The fibromyalgia syndrome (FM) seems an unlikely candidate for classification as a neuropathic pain. The disorder is diagnosed based on a compatible history and the presence of multiple areas of musculoskeletal tenderness. A consistent pathology in either the peripheral or central nervous system (CNS) has not been demonstrated in patients with FM, and they are not at higher risk for diseases of the CNS such as multiple sclerosis or of the peripheral nervous system such as peripheral neuropathy. A large proportion of FM suf- ferers have accompanying symptoms and signs of uncertain etiology, such as chronic fatigue, sleep distur- bance, and bowel/bladder irritability. With the exception of migraine headaches and possibly irritable bowel syndrome, the accompanying disorders are clearly not neurological in origin. The impetus to classify the FM as a neuropathic pain comes from multiple lines of research suggesting widespread pain and tenderness are associated with chronic sensitization of the CNS.
    [Show full text]
  • Fibromyalgia
    The Voice of the Patient A series of reports from the U.S. Food and Drug Administration’s (FDA’s) Patient-Focused Drug Development Initiative Fibromyalgia Public Meeting: March 26, 2014 Report Date: October 2014 Center for Drug Evaluation and Research (CDER) U.S. Food and Drug Administration (FDA) Table of Contents Introduction ......................................................................................................................................3 Meeting overview ..................................................................................................................................... 3 Report overview and key themes ............................................................................................................. 4 Topic 1: Disease Symptoms and Daily Impacts That Matter Most to Patients .......................................5 Perspectives on most significant symptoms ............................................................................................. 6 Overall impact of fibromyalgia on daily life .............................................................................................. 8 Topic 2: Patient Perspectives on Treatments for Fibromyalgia .............................................................9 Prescriptions and over-the-counter drugs ................................................................................................ 9 Non-drug therapies ................................................................................................................................
    [Show full text]
  • Amitriptyline Information Booklet
    Drug information Amitriptyline AMITRIPTYLINE is used to relieve pain in several long-term conditions including arthritis, back pain and fibromyalgia Amitriptyline information booklet Introduction • arthritis (arth-rye-tus) • back pain Amitriptyline (a-muh-trip-tuh-leen) is a drug that can reduce your • fibromyalgia (fie-bruh-my-al-juh) pain and discomfort, and help you get a good night’s sleep. • tension headaches and migraines You can discuss the benefits and risks of taking amitriptyline with • damage to nerve endings in limbs, which may be described to healthcare professionals before you start treatment, so you’re able you as peripheral neuropathy (pe-rif-er-ul new-ro-pa-thee). to make an informed decision. You may not be able to take amitriptyline if: What is amitriptyline and how is it used? • you’ve had an allergic reaction to a medication in the past • you have heart problems, as it can make them worse Amitriptyline is a type of drug called a tricyclic antidepressant. • you have uncontrolled bipolar disorder These drugs were originally developed to treat anxiety and depression, but when taken at a low dose they can reduce or • you have the rare inherent blood disorder porphyria stop pain. (por-fear-ee-ya) which affects the nervous system • you have liver or kidney problems Amitriptyline works by increasing the amount of serotonin your • you have epilepsy, as it can increase the risk of seizures brain makes. Serotonin is a chemical, called a neurotransmitter, that • you’ve had or are having treatment for depression, as some the brain sends out to nerves in the body.
    [Show full text]
  • Milnacipran, a Serotonin and Norepinephrine Reuptake Inhibitor: a Novel Treatment for Fibromyalgia
    Drug Evaluation Milnacipran, a serotonin and norepinephrine reuptake inhibitor: a novel treatment for fibromyalgia Milnacipran hydrochloride is a serotonin (5-HT) and norepinephrine (NE) reuptake inhibitor that was recently approved by the US FDA for the treatment of fibromyalgia (FM). Evidence has accumulated suggesting that, in animal models, milnacipran may exert pain-mitigating influences involving norepinephrine- and serotonin-related processes at supraspinal, spinal and peripheral levels in pain transmission. Milnacipran has demonstrated efficacy for the reduction of pain as well as improvements in global assessments of well-being and functional capacity among treated FM patients. Its role in addressing comorbidities associated with FM, including visceral pain and migraine, has, as yet, to be investigated. Milnacipran may be of special interest for use in patients for whom hepatic dysfunction precludes the use of other agents, for example, duloxetine. It has a negligible influence on cytochrome metabolism, and therefore may be of particular benefit in patients requiring multiple concurrently prescribed medications. Milnacipran may comprise a reasonable option in the armamentarium of treatments available to manage FM. KEYWORDS: antidepressants n chronic pain n fibromyalgian milnacipran n serotonin Raphael J Leo and norepinephrine reuptake inhibitor Department of Psychiatry, School of Medicine and Fibromyalgia (FM) is a syndrome characterized Several pharmacological approaches have Biomedical Sciences, by chronic, widespread musculoskeletal pain and been advocated for the treatment of FM. State University of New York at tenderness. The prevalence of FM in the general Because of their impact on these presump- Buffalo, Erie County Medical population is estimated to be 2–4%; it tends to tive pathophysiologic processes, antidepres- Center, 462 Grider Street, show a female predilection, and increases with sants have frequently been advocated for Buffalo, NY 14215, USA age [1,2].
    [Show full text]
  • Beyond Depression: Other Uses for Tricyclic Antidepressants
    REVIEW Joanne Schneider, DNP, RN, CNP Mary Patterson, CNP Xavier F. Jimenez, MD, MA Center for Comprehensive Pain Recovery, Center for Comprehensive Pain Recovery, Center for Comprehensive Pain Recovery, Neurological Institute, Cleveland Clinic Neurological Institute, Cleveland Clinic Neurological Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH Beyond depression: Other uses for tricyclic antidepressants ABSTRACT ost tricyclic antidepressants (TCAs) M have US Food and Drug Administration Tricyclic antidepressants (TCAs) were originally designed approval for treatment of depression and anxi- and marketed for treating depression, but over time they ety disorders, but they are also a viable off-label have been applied to a variety of conditions, mostly off- option that should be considered by clinicians label. TCAs can serve as first-line or augmenting drugs in specialties beyond psychiatry, especially for for neuropathic pain, headache, migraine, gastrointesti- treating pain syndromes. Given the ongoing nal syndromes, fibromyalgia, pelvic pain, insomnia, and epidemic of opioid use disorder, increasing atten- psychiatric conditions other than depression. This article tion has been drawn to alternative strategies for reviews pharmacology, dosing, and safety considerations chronic pain management, renewing an interest for these uses. in the use of TCAs. This review summarizes the pharmacologic KEY POINTS properties of TCAs, their potential indications Amitriptyline is the most useful TCA for many painful in conditions other than depression, and safety conditions. considerations. ■ BRIEF HISTORY OF TRICYCLICS TCAs can be especially helpful for patients with a pain syndrome or insomnia with comorbid depression, al- TCAs were originally designed in the 1950s and marketed later for treating depression.
    [Show full text]
  • Acute and Chronic Pain Management in Fibromyalgia: Updates on Pharmacotherapy
    American Journal of Therapeutics 18, 487–509 (2011) Acute and Chronic Pain Management in Fibromyalgia: Updates on Pharmacotherapy Eric S. Hsu, MD* Fibromyalgia (FM) is a mysterious pain syndrome with progressive and widespread pain, explicit areas of tender points, stiffness, sleep disturbance, fatigue, and psychological distress without any obvious disease. FM is commonly perceived as a condition of central pain and sensory aug- mentation. There are documented functional abnormalities in pain and sensory processing in FM. Central sensitization and lack of descending analgesic activity are the 2 leading mechanisms that have been demonstrated by advance in both basic and clinical research. The pathogenesis of FM may also be attributed to the genetic polymorphisms involving serotoninergic, dopaminergic, and catecholaminergic systems. Any psychiatric disorders and psychosocial influences in FM may also affect the severity of pain. The various external stimuli or trigger such as infection, trauma, and stress may all contribute to proceed to presentation of FM. The recent launches of 3 US Food and Drug Administration–approved pharmacotherapy for FM namely pregabalin, duloxetine, and milnacipran have certainly raised the profile of optimal chronic pain management. However, appropriate eval- uation and efficacious management of acute pain has not been as well publicized as chronic pain in FM. Acute pain or flare up caused by any trauma or surgery certainly may present a real challenge for patients with FM and their health care providers. Pre-emptive analgesia and pro-active treatment may offer the momentum for acute pain control based on model of central sensitization and pain in FM. This review article on FM appraises the modern practice of multimodal therapy focus on both acute and chronic pain management.
    [Show full text]