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Cashin AG, Wand BM, O'Connell NE, Lee H, Rizzo RR, Bagg MK, O'Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2023; 4:CD013815. [PMID: 37014979 PMCID: PMC10072849 DOI: 10.1002/14651858.cd013815.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Pharmacological interventions are the most used treatment for low back pain (LBP). Use of evidence from systematic reviews of the effects of pharmacological interventions for LBP published in the Cochrane Library, is limited by lack of a comprehensive overview. OBJECTIVES To summarise the evidence from Cochrane Reviews of the efficacy, effectiveness, and safety of systemic pharmacological interventions for adults with non-specific LBP. METHODS The Cochrane Database of Systematic Reviews was searched from inception to 3 June 2021, to identify reviews of randomised controlled trials (RCTs) that investigated systemic pharmacological interventions for adults with non-specific LBP. Two authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools. The review focused on placebo comparisons and the main outcomes were pain intensity, function, and safety. MAIN RESULTS Seven Cochrane Reviews that included 103 studies (22,238 participants) were included. There is high confidence in the findings of five reviews, moderate confidence in one, and low confidence in the findings of another. The reviews reported data on six medicines or medicine classes: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants. Three reviews included participants with acute or sub-acute LBP and five reviews included participants with chronic LBP. Acute LBP Paracetamol There was high-certainty evidence for no evidence of difference between paracetamol and placebo for reducing pain intensity (MD 0.49 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.99 to 2.97), reducing disability (MD 0.05 on a 0 to 24 scale (higher scores indicate worse disability), 95% CI -0.50 to 0.60), and increasing the risk of adverse events (RR 1.07, 95% CI 0.86 to 1.33). NSAIDs There was moderate-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo at reducing pain intensity (MD -7.29 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.98 to -3.61), high-certainty evidence for a small between-group difference for reducing disability (MD -2.02 on a 0-24 scale (higher scores indicate worse disability), 95% CI -2.89 to -1.15), and very low-certainty evidence for no evidence of an increased risk of adverse events (RR 0.86, 95% CI 0. 63 to 1.18). Muscle relaxants and benzodiazepines There was moderate-certainty evidence for a small between-group difference favouring muscle relaxants compared to placebo for a higher chance of pain relief (RR 0.58, 95% CI 0.45 to 0.76), and higher chance of improving physical function (RR 0.55, 95% CI 0.40 to 0.77), and increased risk of adverse events (RR 1.50, 95% CI 1. 14 to 1.98). Opioids None of the included Cochrane Reviews aimed to identify evidence for acute LBP. Antidepressants No evidence was identified by the included reviews for acute LBP. Chronic LBP Paracetamol No evidence was identified by the included reviews for chronic LBP. NSAIDs There was low-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo for reducing pain intensity (MD -6.97 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.74 to -3.19), reducing disability (MD -0.85 on a 0-24 scale (higher scores indicate worse disability), 95% CI -1.30 to -0.40), and no evidence of an increased risk of adverse events (RR 1.04, 95% CI -0.92 to 1.17), all at intermediate-term follow-up (> 3 months and ≤ 12 months postintervention). Muscle relaxants and benzodiazepines There was low-certainty evidence for a small between-group difference favouring benzodiazepines compared to placebo for a higher chance of pain relief (RR 0.71, 95% CI 0.54 to 0.93), and low-certainty evidence for no evidence of difference between muscle relaxants and placebo in the risk of adverse events (RR 1.02, 95% CI 0.67 to 1.57). Opioids There was high-certainty evidence for a small between-group difference favouring tapentadol compared to placebo at reducing pain intensity (MD -8.00 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.22 to -0.38), moderate-certainty evidence for a small between-group difference favouring strong opioids for reducing pain intensity (SMD -0.43, 95% CI -0.52 to -0.33), low-certainty evidence for a medium between-group difference favouring tramadol for reducing pain intensity (SMD -0.55, 95% CI -0.66 to -0.44) and very low-certainty evidence for a small between-group difference favouring buprenorphine for reducing pain intensity (SMD -0.41, 95% CI -0.57 to -0.26). There was moderate-certainty evidence for a small between-group difference favouring strong opioids compared to placebo for reducing disability (SMD -0.26, 95% CI -0.37 to -0.15), moderate-certainty evidence for a small between-group difference favouring tramadol for reducing disability (SMD -0.18, 95% CI -0.29 to -0.07), and low-certainty evidence for a small between-group difference favouring buprenorphine for reducing disability (SMD -0.14, 95% CI -0.53 to -0.25). There was low-certainty evidence for a small between-group difference for an increased risk of adverse events for opioids (all types) compared to placebo; nausea (RD 0.10, 95% CI 0.07 to 0.14), headaches (RD 0.03, 95% CI 0.01 to 0.05), constipation (RD 0.07, 95% CI 0.04 to 0.11), and dizziness (RD 0.08, 95% CI 0.05 to 0.11). Antidepressants There was low-certainty evidence for no evidence of difference for antidepressants (all types) compared to placebo for reducing pain intensity (SMD -0.04, 95% CI -0.25 to 0.17) and reducing disability (SMD -0.06, 95% CI -0.40 to 0.29). AUTHORS' CONCLUSIONS We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high-certainty evidence for no evidence of difference between paracetamol and placebo. For safety, we found very low- and high-certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate-certainty evidence that muscle relaxants may increase the risk of adverse events. For chronic LBP, we found low-certainty evidence that NSAIDs and very low- to high-certainty evidence that opioids may provide a small effect on pain. For safety, we found low-certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low-certainty evidence that opioids may increase the risk of adverse events.
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Affiliation(s)
- Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Rodrigo Rn Rizzo
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Matthew K Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
- New College Village, University of New South Wales, Sydney, Australia
| | - Edel O'Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
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Ferraro MC, Bagg MK, Wewege MA, Cashin AG, Leake HB, Rizzo RRN, Jones MD, Gustin SM, Day R, Loo CK, McAuley JH. Efficacy, acceptability, and safety of antidepressants for low back pain: a systematic review and meta-analysis. Syst Rev 2021; 10:62. [PMID: 33627178 PMCID: PMC7905649 DOI: 10.1186/s13643-021-01599-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/26/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Antidepressant medicines are used to manage symptoms of low back pain. The efficacy, acceptability, and safety of antidepressant medicines for low back pain (LBP) are not clear. We aimed to evaluate the efficacy, acceptability, and safety of antidepressant medicines for LBP. METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov , the EU Clinical Trials Register, and the WHO International Clinical Trial Registry Platform from inception to May 2020. We included published and trial registry reports of RCTs that allocated adult participants with LBP to receive an antidepressant medicine or a placebo medicine. Pairs of authors independently extracted data in duplicate. We extracted participant characteristics, study sample size, outcome values, and measures of variance for each outcome. We data using random-effects meta-analysis models and calculated estimates of effects and heterogeneity for each outcome. We formed judgments of confidence in the evidence in accordance with GRADE. We report our findings in accordance with the PRISMA statement. We prespecified all outcomes in a prospectively registered protocol. The primary outcomes were pain intensity and acceptability. We measured pain intensity at end-of-treatment on a 0-100 point scale and considered 10 points the minimal clinically important difference. We defined acceptability as the odds of stopping treatment for any reason. RESULTS We included 23 RCTs in this review. Data were available for pain in 17 trials and acceptability in 14 trials. Treatment with antidepressants decreased pain intensity by 4.33 points (95% CI - 6.15 to - 2.50) on a 0-100 scale, compared to placebo. Treatment with antidepressants increased the odds of stopping treatment for any reason (OR 1.27 [95% CI 1.03 to 1.56]), compared to placebo. CONCLUSIONS Treatment of LBP with antidepressants is associated with small reductions in pain intensity and increased odds of stopping treatment for any reason, compared to placebo. The effect on pain is not clinically important. The effect on acceptability warrants consideration. These findings provide Level I evidence to guide clinicians in their use of antidepressants to treat LBP. TRIAL REGISTRATION We prospectively registered the protocol for this systematic review on PROSPERO ( CRD42020149275 ).
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Affiliation(s)
- Michael C. Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Matthew K. Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
- New College Village, University of New South Wales, Sydney, Australia
| | - Michael A. Wewege
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Aidan G. Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Hayley B. Leake
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- IIMPACT in Health, University of South Australia, Adelaide, Australia
| | - Rodrigo R. N. Rizzo
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Matthew D. Jones
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Health Sciences, University of New South Wales, Sydney, Australia
| | - Sylvia M. Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Richard Day
- Clinical Pharmacology & Toxicology, St. Vincent’s Hospital, Sydney, Australia
- St. Vincent’s Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Colleen K. Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia
- Black Dog Institute, Sydney, Australia
| | - James H. McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW Australia
- School of Health Sciences, University of New South Wales, Sydney, Australia
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Cashin AG, Wand BM, O'Connell NE, Lee H, Bagg MK, O'Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Hippokratia 2020. [DOI: 10.1002/14651858.cd013815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Aidan G Cashin
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Benedict M Wand
- School of Physiotherapy; The University of Notre Dame Australia; Fremantle Australia
| | - Neil E O'Connell
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences; Brunel University London; Uxbridge UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); University of Oxford; Oxford UK
- School of Medicine and Public Health; University of Newcastle; Newcastle Australia
| | - Matthew K Bagg
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- New College Village; University of New South Wales; Sydney Australia
| | - Edel O'Hagan
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Christopher G Maher
- Sydney School of Public Health; The University of Sydney; Sydney Australia
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences; VU University Amsterdam; Amsterdam Netherlands
| | - James H McAuley
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- School of Medical Sciences, Faculty of Medicine; University of New South Wales; Sydney Australia
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Urquhart DM, Wluka AE, Sim MR, van Tulder M, Forbes A, Gibson SJ, Arnold C, Fong C, Anthony SN, Cicuttini FM. Is low-dose amitriptyline effective in the management of chronic low back pain? Study protocol for a randomised controlled trial. Trials 2016; 17:514. [PMID: 27770809 PMCID: PMC5075416 DOI: 10.1186/s13063-016-1637-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 10/04/2016] [Indexed: 12/25/2022] Open
Abstract
Background Low back pain is a major clinical and public health problem, with limited evidence-based treatments. Low-dose antidepressants are commonly used to treat pain in chronic low back pain. However, their efficacy is unproven. The aim of this pragmatic, double-blind, randomised, placebo-controlled trial is to determine whether low-dose amitriptyline (an antidepressant) is more effective than placebo in reducing pain in individuals with chronic low back pain. Methods/design One hundred and fifty individuals with chronic low back pain will be recruited through hospital and private medical and allied health clinics, advertising in local media and posting of flyers in community locations. They will be randomly allocated to receive either low-dose amitriptyline (25 mg) or an active placebo (benztropine mesylate, 1 mg) for 6 months. The primary outcome measure of pain intensity will be assessed at baseline, 3 and 6 months using validated questionnaires. Secondary measures of self-reported low back disability, work absence and hindrance in the performance of paid/unpaid work will also be examined. Intention-to-treat analyses will be performed. Discussion This pragmatic, double-blind, randomised, placebo-controlled trial will provide evidence regarding the effectiveness of low-dose antidepressants compared with placebo in reducing pain, disability, work absenteeism and hindrance in work performance in individuals with chronic low back pain. This trial has major public health and clinical importance as it has the potential to provide an effective approach to the management of chronic low back pain. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12612000131853; registered on 30 January 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1637-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donna M Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia.
| | - Anita E Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Malcolm R Sim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Maurits van Tulder
- Department of Health Sciences and EMGO+, Institute for Health and Care Research, VU University, 1081 HV, Amsterdam, The Netherlands
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Stephen J Gibson
- National Ageing Research Institute, Parkville, Melbourne, 3052, VIC, Australia.,Caulfield Pain Management and Research Centre, Caulfield, Melbourne, 3162, VIC, Australia
| | - Carolyn Arnold
- Caulfield Pain Management and Research Centre, Caulfield, Melbourne, 3162, VIC, Australia.,Department of Anaesthesia and Perioperative Medicine, Monash University, Alfred Hospital, Melbourne, 3004, VIC, Australia
| | - Chris Fong
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Box Hill, Melbourne, 3128, VIC, Australia
| | - Shane N Anthony
- Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, 3800, VIC, Australia
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC, 3004, Australia
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Hepburn S, Harden J, Grieve JHK, Hiscox J. Deliberate Misuse of Tricyclic Antidepressants by Intravenous Drug Users - Case Studies and Report. Scott Med J 2016; 50:131-3. [PMID: 16164005 DOI: 10.1177/003693300505000316] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S Hepburn
- Department of Emergency Medicine, Aberdeen Royal Infirmary
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Evaluation the efficacy of intrathecal injection of amitryptiline and doxepin in spinal anesthesia and in comparison with bupivacaine in rats. Anesth Pain Med 2011. [DOI: 10.5812/aapm.1511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Alebouyeh MR, Imani F, Rahimzadeh P, Faiz SHR. Evaluation of the efficacy of intrathecal injection of amitriptyline and doxepin in spinal anesthesia in comparison with bupivacaine in rats. Anesth Pain Med 2011; 1:15-9. [PMID: 25729650 PMCID: PMC4335756 DOI: 10.5812/kowsar.22287523.1511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 06/03/2011] [Accepted: 06/08/2011] [Indexed: 11/16/2022] Open
Abstract
Background: Tricyclic antidepressants (TCAs) are commonly used orally for treating chronic pain states, such as neuropathic pain. TCAs produce analgesia by various mechanisms, including sodium channels, N-methyl-d-aspartate receptors, biogenic amines, opioids, inflammatory mediators, and substance P. Studies have shown that intrathecal tricyclic administration effectively attenuates pain and thermal hyperalgesia in inflammatory and neuropathic pain in rats. Objectives: The aim of this study was to evaluate the effect of two tertiary TCAs in sensory and motor block. We also used bupivacaine as a strong local anesthetic for the control group. Materials and Methods: In a double-blind randomized controlled trial in an animal lab, intrathecal injection of drugs was performed in 30 Wistar male rats. We divided the subjects into 3 groups: group 1: 90 µL Doxepine (50 mM), group 2: 90 µl amitriptyline (60 mM). and group 3: 90 µL bupivacaine (23 mM). Then sensory, motor, and proprioceptive changes were measured at 1, 2, 3, 4, 6, and 12 hours by one examiner. Results: In Groups 1 and 2, a total of 3 rats died. After adjusting the concentrations, amitriptyline had a similar potency but a longer duration of spinal blockade of motor, proprioception, and nociception than did bupivacaine (p < 0.05), whereas doxepin had a reasonable but lower efficacy and shorter duration of spinal blockade than did bupivacaine (p < 0.05). The full recovery time for Group 2 was significantly longer. Conclusions: It seems that tertiary amine drugs such as amitriptyline and doxepin had reasonable potencies of spinal blockade when compared to bupivacaine. However, amitriptyline had a more potent and long-acting spinal anesthetic effect. Amitriptyline may turn out to be a clinically valuable local anesthetic.
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Affiliation(s)
- Mahmoud Reza Alebouyeh
- Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Farnad Imani
- Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Poupak Rahimzadeh
- Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Poupak Rahimzadeh, Department of Anesthesiology and Pain Medicine, Rasoul-Akram Medical Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel/Fax: +98-2166509059, E-mail:
| | - Seyyed Hamid Reza Faiz
- Department of Anesthesiology, Rasoul-Akram Medical Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Sun XY, Zhang L, Wei CX, Piao HR, Quan ZS. Characterization of the anticonvulsant activity of doxepin in various experimental seizure models in mice. Pharmacol Rep 2009; 61:245-51. [PMID: 19443935 DOI: 10.1016/s1734-1140(09)70028-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 02/18/2009] [Indexed: 11/16/2022]
Abstract
In this paper, the anticonvulsant characteristics of doxepin were evaluated in numerous experimental seizure models, including maximal electroshock (MES)-, pentylenetetrazole (PTZ)-, isoniazid (ISO)-, 3-mercaptopropionic acid (3-MP)-, bicuculline (BIC)-, thiosemicarbazide (THIO)-, and strychnine (STR)-induced seizures. In addition, the acute adverse-effect profile of doxepin with respect to impairment of motor coordination was assessed with a mouse rotarod test. The evaluation of the time-course and dose-response relationships for doxepin provided evidence that the peak maximum anticonvulsant activity and acute adverse effects occurred 5 min after intraperitoneal (ip) administration. The results also revealed that doxepin had excellent anticonvulsant activity against maximal electroshock-induced seizures in mice with a median effect value (ED(50)) of 6.6 mg/kg. The assessment of acute adverse effects in the rotarod test revealed that doxepin induced acute neurotoxicity, and its median toxic dose (TD(50)) was 26.4 mg/kg. Additionally, doxepin showed anticonvulsant activity in several chemically-induced seizure models, including ISO, 3-MP, BIC, and THI. Based on this study, we can conclude that the antidepressant drug doxepin may be useful for treatment of depression in patients with epilepsy due to its short time to peak maximum anticonvulsant activity after ip administration (5 min) and remarkable anticonvulsant activity (6.6 mg/kg).
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Affiliation(s)
- Xian-Yu Sun
- Key Laboratory of Organism Functional Factors of the Changbai Mountain, Yanbian University, Ministry of Education, Yanji, Jilin, 133002, China
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Urquhart DM, Hoving JL, Assendelft WWJJ, Roland M, van Tulder MW. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev 2008; 2008:CD001703. [PMID: 18253994 PMCID: PMC7025781 DOI: 10.1002/14651858.cd001703.pub3] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antidepressants are commonly used in the management of low-back pain. However, their use is controversial. OBJECTIVES The aim of this review was to determine whether antidepressants are more effective than placebo for the treatment of non-specific low-back pain. SEARCH STRATEGY Randomised controlled trials were identified from MEDLINE and EMBASE (to September 2007), PsycINFO to June 2006, the Cochrane Central Register of Controlled Trials 2006, issue 2, and previous systematic reviews. SELECTION CRITERIA We included randomised controlled trials that compared antidepressant medication and placebo for patients with non-specific low-back pain, and used at least one clinically relevant outcome measure. DATA COLLECTION AND ANALYSIS Two blinded review authors independently extracted data and assessed the methodological quality of the trials. Meta-analyses were used to examine the effect of antidepressants on pain, depression and function, and the effect of antidepressant type on pain. To account for studies that could not be pooled, additional qualitative analyses were performed using the levels of evidence recommended by the Cochrane Back Review Group. MAIN RESULTS Ten trials that compared antidepressants with placebo were included in this review. The pooled analyses showed no difference in pain relief (six trials; standardized mean difference (SMD) -0.06 (95% confidence interval (CI) -0.28 to 0.16)) or depression (two trials; SMD 0.06 (95% CI -0.29 to 0.40)) between antidepressant and placebo treatments. The qualitative analyses found conflicting evidence on the effect of antidepressants on pain intensity in chronic low-back pain, and no clear evidence that antidepressants reduce depression in chronic low-back pain patients. Two pooled analyses showed no difference in pain relief between different types of antidepressants and placebo. Our findings were not altered by the sensitivity analyses which varied the level of methodological quality required for inclusion in the meta-analyses to allow data from additional trials to be examined. Two additional trials were identified in September 2007 and await assessment. AUTHORS' CONCLUSIONS There is no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low-back pain. These findings do not imply that severely depressed patients with back pain should not be treated with antidepressants; furthermore, there is evidence for their use in other forms of chronic pain.
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Affiliation(s)
- D M Urquhart
- Monash University - Central and Eastern Clinical School Alfred, Department of Epidemiology and Preventive Medicine, Hospital Commercial Rd Melbourne 3004, Melbourne, Victoria, Australia, 3004.
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Abstract
PURPOSE OF REVIEW This review discusses clinically oriented data on advances in pharmacological research of cancer pain therapy carried out during the last year. The aim is to ascertain whether well known guidelines for cancer pain prove to be adequate or require modification. RECENT FINDINGS There are alternatives to morphine, which is the standard drug, including oxycodone or methadone, with the problem of equivalence doses in the case of opioid rotation. Depending on the underlying pathophysiological mechanisms, adjuvant drugs are recommended, such as antidepressants and anticonvulsants for neuropathic pain, or bisphosphonates for metastasis bone pain. Current and future research will offer receptor-specific acting new drugs or old drugs under new indications. SUMMARY The recommendations of the World Health Organization ladder remain the mainstay of cancer pain management. These recommendations, however, are based more on expert opinions than on evidence-based data.
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Affiliation(s)
- Ingrid Gralow
- Department of Anesthesiology and Intensive Care, Pain Clinic, University Clinic of Münster, Germany.
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Cheng BC, Chan BR, Chen YW, Chu KS, Cheng KI, Wang JJ, Chu CC. Doxepin Has a Potent and Long-Acting Spinal Anesthetic Effect in Rats. Kaohsiung J Med Sci 2006; 22:68-74. [PMID: 16568723 DOI: 10.1016/s1607-551x(09)70223-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Doxepin, a tricyclic antidepressant, was recently found to be effective in the treatment of various acute and chronic painful conditions. However, the mechanism of its actions was not clear, especially when involving the spine. The aim of our study was to evaluate the spinal anesthetic effect of doxepin. Two commonly used traditional local anesthetics, bupivacaine and lidocaine, were used as controls. The potencies and durations of the drugs' action were evaluated in male Sprague-Dawley rats. We found that intrathecally administered doxepin, like bupivacaine and lidocaine, produced dose-related spinal anesthetic effects on motor activity, proprioception, and nociception. Among the three drugs, doxepin produced spinal anesthetic effects in rats more potent than that of lidocaine (p < 0.001, in each comparison) and longer than that of bupivacaine and lidocaine (p < 0.001, in each comparison). The spinal activity of doxepin may provide some explanation of its clinical effect in pain management.
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Affiliation(s)
- Bor-Chin Cheng
- Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
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Abstract
Trauma is a major cause of mortality throughout the world. In recent years, major advances have been made in the management of trauma, the end result of which has been reduced mortality and enhanced function. One of these areas is pain control. Improved pain management has not only led to increased comfort in trauma patients, but has also been shown to reduce morbidity and improve long-term outcomes. This review focuses on the treatment of pain in the setting of acute injury and on pain management in trauma patients who go on to develop chronic pain. Emphasis is placed on pharmacologic interventions, invasive and noninvasive pain management techniques, analgesia in challenging patients, and pain control in commonly encountered trauma conditions.
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Affiliation(s)
- Steven P Cohen
- Pain Management Center, Department of Anesthesiology, New York University School of Medicine, New York, NY, USA
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