Selected tricyclic antidepressants in the management of chronic benign pain

Depression is often considered a symptom of intractable benign pain and is usually a situational or exogenous subtype. At our four hospital-based pain management centers we have evaluated and treated more than 5,000 patients for chronic pain. The treatment of more than 2,000 of these patients has included the administration of doxepin or amitriptyline. This article reviews the therapeutic use of selected tricyclic antidepressants in the treatment of chronic benign pain and depression, and emphasizes the blockage of serotonin reuptake as the mechanism of action. The benefits of doxepin and amitriptyline include sleep facilitation, low cardiotoxicity and incidence of anticholinergic effects, and anxiolytic properties.

Piroxicam and doxepin--an alternative to narcotic analgesics in managing advanced cancer pain

To provide an effective continuum of the relief of severe carcinomatous pain with minimal side reactions, we initiated treatment with piroxicam (60 to 120 mg per day) and doxepin hydrochloride (25 to 225 mg per day). Of 30 patients presenting with severe pain of cancer of various origins, 7 continued to death with piroxicam and doxepin therapy. An additional 17 were successfully treated for 6 to 66 weeks with therapy reported here but, as disease progressed, required supplemental narcotics. The remaining six abandoned the use of piroxicam due to complications of therapy, which ranged from diarrhea to gastric perforation; serious complications were associated with patients' failure to adhere to a prescribed regimen of sucralfate. Therapy with piroxicam and doxepin proved to be safe and efficacious.

Dysthymia: a randomized study of cognitive marital therapy and antidepressants

Preliminary data from a randomized study of the effectiveness of combined marital therapy and antidepressant medication in the treatment of dysthymic married women is presented. The study compares doxepin with placebo, and a marital therapy designed to enhance intimacy through facilitating self-disclosure between spouses with a more supportive and educational therapeutic approach. After ten weeks of combined treatment, the dysthymic women show statistically significant improvement on all the depression measures as well as on the intimacy scale. A trend is developing for greater reduction of depressive symptomatology in the group treated with self-disclosure. The evidence appears to suggest the possibility that the presence of a patient's husband as a supportive figure may of itself be a potent therapeutic manoeuvre in the treatment of dysthymic women.

Improvement of chronic neurotic excoriations with oral doxepin therapy

Two patients with 6- to 7-year histories of neurotic excoriations refractory to the usual dermatologic management were referred for evaluation. Both had symptoms and signs of depression associated with the onset and persistence of the skin condition. Doxepin, a tricyclic antidepressant therapy with potent antihistamine properties, was used in oral doses of 30-75 mg daily for our patients. This therapy resulted in symptomatic and clinical improvement in both patients within several weeks. This limited report of apparent benefit of doxepin in two patients with neurotic excoriations and depression offers a potential therapy in the management of this challenging clinical problem.

Post-amputation phantom pain and autonomous stump movements responsive to doxepin

A 40-year old man with post-amputation phantom pain and involuntary autonomous movements experienced dramatic relief of both pain and autonomous movements with administration of the antidepressant doxepin. The pathophysiology of pain and post-amputation autonomous movements, as well as the therapeutic response to doxepin are discussed in terms of the effects of limb amputation on spinal excitability and alterations in both spinal and supraspinal transmitter functions.

Cardiovascular effects of doxepin in cardiac patients with ventricular arrhythmias

The effect of doxepin on ventricular arrhythmias, the ECG, and left ventricular function was evaluated in 10 cardiac patients with symptoms with frequent ventricular premature depolarizations in a dose-ranging protocol. Four patients (40%) had greater than or equal to 80% ventricular premature depolarization suppression; four of eight with pairs and four of six with ventricular tachycardia had greater than or equal to 90% suppression. The mean maximal doxepin dose was 115 +/- 41 mg/day; mean nadir total doxepin concentration was 61 +/- 48 ng/ml and mean nadir total desmethyldoxepin concentration was 51 +/- 42 ng/ml. Doxepin increased the heart rate and the PR, QRS, and QTc intervals of the surface ECG (P not significant). There was no significant change in resting mean left ventricular ejection fraction with doxepin: 41% +/- 15% vs. 43% +/- 19% (P not significant). Complaints of sedation (eight patients) limited dose ranging and tolerance to the drug. Although doxepin suppressed ventricular premature depolarizations in four patients, marked sedation limits its usefulness for primary treatment of arrhythmias in this population.

Antidepressant treatment of medical-surgical inpatients by nonpsychiatric physicians

The prescribing of antidepressants by nonpsychiatric physicians on adult medical-surgical inpatient services of a university hospital was examined through the review of medical records of patients who received amitriptyline hydrochloride, doxepin hydrochloride, or imipramine hydrochloride during a one-year period. Reasons for antidepressant use were treatment of depression (56%), pain (30%), or other conditions (14%). Regardless of the reason for use, nonpsychiatric physicians were found to use relatively low dosages, rarely plan or effect dosage increases, and rarely discontinue medication.

Antidepressants: their uses in nonpsychiatric disorders of aging

Antidepressants are recommended by some clinicians as therapy for irritable colon even when there is no evidence of clinical depression, since this syndrome may represent a type of chronic masked depression. Antidepressants may be a good alternative in elderly patients with peptic ulcer disease, particularly in those with concurrent depression. Advantages include once-a-day administration, lower cost, and ease of serum monitoring.

Tricyclic antidepressants for chronic low-back pain. Mechanisms of action and predictors of response

Patients with chronic low-back pain and depression were treated double blind with desipramine or doxepin. During this treatment several hypotheses regarding the modes of action of these drugs were examined. A low serotonin hypothesis was supported by the fact that patients who had pain relief following an acute challenge with fenfluramine, a relatively pure releaser of serotonin, were significantly more likely to have pain relief on either antidepressant. The antidepressants did not change cerebrospinal fluid (CSF) beta-endorphin levels, acute pain tolerance, or electromyogram (EMG) levels. The nonsedating antidepressant desipramine was as effective as doxepin; 60% of patients had significant pain relief. Pain relief was associated with depression relief, but several patients had only pain or depression relief. Patients who had a substantial physical basis for their pain responded as well as those who did not.

Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria

The acquired cold urticaria (ACU) syndromes consists of nonfamilial heterogeneous disorders characterized by urticaria, angioedema, and occasionally symptoms of hypotension after cold exposure. In a study of 50 consecutive patients with ACU syndromes, it was observed that 70% experienced cold-induced systemic reactions, most frequently with aquatic activities. Patients with ACU syndromes were categorized by their response to an experimental cold-stimulation time test (CSTT) i.e., minimum time threshold of cold stimulation required to induce a coalescent wheal. One subpopulation of patients with ACU syndromes with positive CSTTs of 3 minutes or less experienced the highest incidence (68%; 13/19) of severe systemic reactions with hypotensive symptoms after natural cold exposure. However, 32% of patients with ACU syndromes (6/19) who experienced cold-induced systemic reactions with hypotension had a negative CSTT or a positive test of greater than 3 minutes. These observations indicate that all patients with ACU with active histories of cold urticaria are at risk to develop systemic reactions to cold and should therefore refrain from participating in aquatic activities. In addition, high-risk patients should receive prophylactic medications (i.e., cyproheptadine or doxepin) that are effective in suppressing this disorder. A diagnostic classification of cold urticaria is presented. This classification permits a more specific definition of the various cold urticaria disorders that comprise the ACU syndromes.

Combined cold- and heat-induced cholinergic urticaria

A 36-year-old white woman with a 20-year history of cutaneous, respiratory, and cardiovascular symptoms triggered by physical activity and by exposure to either heat or cold was evaluated. A routine evaluation for the cause of her condition was positive only for certain physical factors. Cutaneous testing for dermatographism, ice-cube challenge, and exposure to ultraviolet A and ultraviolet B light were negative. A methacholine skin test was positive. Sitting in a cold room (4 degrees C) induced micropapular wheals on exposed areas similar to those classically associated with cholinergic urticaria. Placing both feet in warm water (44 degrees C) induced similar but more intense cutaneous lesions at sites not exposed to heat, light headedness, and severe asthma. Exercise for 10 minutes caused confluent and punctate urticarial lesions. Simultaneous measurement of plasma histamine during cold and heat challenges revealed increases paralleling the course of symptoms. Repeat challenge with cold, heat, and exercise after beginning treatment with both H1 and H2 histamine antagonists resulted in marked reduction in symptoms; however, significant rises in plasma histamines were still noted.

Doxepin treatment of depressed patients with chronic obstructive pulmonary disease

During each of two six-week treatment periods, 12 depressed outpatients with chronic obstructive pulmonary disease received increasing doses of doxepin hydrochloride or a placebo as tolerated. The mean maximal doses of doxepin hydrochloride and placebo were 105 and 128 mg, respectively. Three of the 12 patients dropped out because of doxepin's side effects. The depression and anxiety scores at the end of the treatment periods were virtually identical and not significantly different from baseline scores. Changes in the 12-minute walking distance were more closely correlated with changes in the depression and anxiety scores than with changes in the forced expiratory volume in 1 s or forced vital capacity. Thus, doxepin is ineffective in treating depressed patients with chronic obstructive pulmonary disease; improvements in the 12-minute walking distance were closely correlated with improvements in the depression or anxiety scores.

Clovoxamine and doxepin in major depressive disorder: a double-blind controlled trial

Clovoxamine, an inhibitor of neuronal uptake of both serotin and noradrenaline, was compared with doxepin in depressed patients over four weeks. Antidepressant efficacy was comparable for both drugs, but clovoxamine might have a special degree of efficacy for patients with more severe depressive illnesses.

A controlled comparison of clonidine and doxepin in the treatment of the opiate withdrawal syndrome

Clonidine and doxepin alleviate the symptoms of the opiate withdrawal syndrome. Clonidine was slightly more effective in controlling sweating, hot flushes, palpitations and nausea, and doxepin was slightly more effective in relieving the craving for opiates, lassitude and depression. Adverse effects such as sedation, dry mouth and falls in blood pressure occurred in both groups. There were six cases of collapse during treatment with high doses of doxepin, whereas only one subjective circulatory effect occurred in the clonidine group. At these high doses, doxepin may cause orthostatic hypotension via a peripheral alpha-receptor blockade. Clonidine reduced pulse rate whereas doxepin, with its anticholinergic action and indirectly via its alpha-receptor blocking action, raised it. Several patients in the doxepin group hat fits, as opposed to only one in the clonidine group. It is possible that the use of barbiturates had reduced the convulsive threshold in some of our patients. Overall, clonidine and doxepin were equipotent at adequate individual dose levels, and both were well tolerated. In this trial, serious side-effects occurred less often in the clonidine group.

Treatment of acute posttraumatic stress disorder with tricyclic antidepressants

The diagnostic concept of posttraumatic stress disorder (PTSD) has long been recognized but usually applied in postwar circumstances. Recently developed criteria have allowed the disorder to be recognized in civilian patients having stress from such common insults as trauma, burns, or rape. Because PTSD may become chronic and difficult to treat if unrecognized, early intervention is desirable. In this report I describe three patients with acute PTSD who had favorable therapeutic response to tricyclic antidepressants. Although the use of the tricyclic agents in PTSD is rational because of their antianxiety and antidepressant properties, little has previously been said of their effectiveness in this disorder. These agents may provide an effective means of diminishing or preventing chronic PTSD.