Cymbalta (duloxetine) will be used more for chronic musculoskeletal pain in the lower back or due to osteoarthritis. Cymbalta is already approved for neuropathic pain. Plus, it's approved for chronic musculoskeletal pain, so physicians are hearing more about this use, too.
Some antidepressants do have analgesic effects, especially tricyclics (amitriptyline, etc) and SNRIs (duloxetine, venlafaxine). They inhibit pain pathways in the CNS. But the modest benefit is sometimes outweighed by side effects. Only 1 of every 5 to 8 patients on Cymbalta for 13 weeks gets a modest 30% reduction in pain intensity, but 1 of every 8 to 12 patients stops it due to an adverse effect.
Recommend trying other approaches first. Suggest exercise, stretching, and heat for low back pain, and weight loss and activity for arthritis. Tell low back pain sufferers not to stay in bed any longer than necessary. If an analgesic is needed, recommend NSAIDs or acetaminophen first.
Suggest a topical NSAID (Voltaren gel, etc) for arthritis pain in the knee, especially in patients at risk for GI bleeding. Suggest trying a tricyclic or SNRI such as Cymbalta if analgesics aren't enough, especially if the patient is also depressed. Explain that tricyclics cost less, but SNRIs are usually better tolerated. Recommend not going over 60 mg/day of Cymbalta for pain, higher doses DON'T work better but DO increase side effects.
References
-
Bellingham GA, Peng PW. Duloxetine: a review of its pharmacology and use in chronic pain management. Reg Anesth Pain Med. 2010 May-Jun;35(3):294-303. Available at: https://rapm.bmj.com/content/35/3/294-303
Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Gen Hosp Psychiatry. 2009 May-Jun;31(3):206-19. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0163834309000036?via%3Dihub
Jann MW, Slade JH. Antidepressant agents for the treatment of chronic pain and depression. Pharmacotherapy. 2007 Nov;27(11):1571-87. Available at: https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1592/phco.27.11.1571
0 تعليقات