Irritable bowel syndrome: low dose antidepressant improves symptoms

The studyFord AC, Wright-Hughes A, Alderson SL, et al. Amitriptyline at low-dose and titrated for irritable bowel syndrome as second-line treatment in primary care (ATLANTIS): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2023;402:1773-85.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/irritable-bowel-syndrome-low-dose-antidepressant-improves-symptoms/.

Effects of Low-Dose Amitriptyline on Epigastric Pain Syndrome in Functional Dyspepsia Patients

AIM

To observe the therapeutic effect of low-dose amitriptyline (AMT) on epigastric pain syndrome (EPS) in patients with functional dyspepsia.

METHODS

Sixty patients with EPS were randomly divided into the following two groups for a four-week clinical trial: routine treatment with pantoprazole (RT group) and the AMT group. The RT group was treated with 40 mg of pantoprazole once daily. The AMT group received 25 mg of AMT once daily before bedtime. The Nepean Dyspepsia Index (NDI) checklist, Hamilton Rating Scale of Anxiety/Depression (HAMA/HAMD), and Pittsburgh Sleep Quality Index (PSQI) were employed to evaluate dyspepsia symptoms, psychological distress, and sleep, respectively.

RESULTS

All items were similar between the two groups before treatment (0 week). After 4 weeks of treatment, the NDI-symptom checklist score as well as the severity and bothersomeness of EPS in the AMT group was significantly decreased compared with those in the RT group (p < 0.05). However, no differences were found in the frequency of NDI checklist, psychological status (HAMD/HAMA scores) of EPS, or sleep quality (PSQI score) between the two groups after treatment. In addition, the time to fall asleep was shorter in the AMT group compared with the RT group after 4 weeks of treatment (p < 0.05).

CONCLUSION

Low-dose AMT effectively improved the dyspepsia symptoms and the time to fall asleep in the EPS patients, compared with pantoprazole, although it did not reduce the psychological distress. Therefore, AMT could be considered as a good candidate for EPS treatment in the clinic.

Amitriptyline prescribing in public sector healthcare facilities in the Western Cape, South Africa

BACKGROUND

Inappropriate medication use is a major patient safety concern, especially for the elderly population. Amitriptyline is widely used in primary care in South Africa and a cross-sectional study found that amitriptyline was prescribed potentially inappropriately in 6.5% of elderly patients. An analysis of prescriptions from the Chronic Dispensing Unit in the Western Cape revealed that amitriptyline was one of the most common medicines prescribed without a suitable diagnosis listed on the prescription.

OBJECTIVE

The main objective of the medicine use evaluation (MUE) was to determine whether amitriptyline was prescribed in accordance with recommendations from standard treatment guidelines (STG) and essential medicines lists (EML) endorsed by the National Department of Health, South Africa.

METHODS

A retrospective, cross-sectional, multicentre review of patients' clinical notes was conducted. The study population was selected by systematic random sampling from adult outpatients who were prescribed amitriptyline for longer than three months. Criteria for evaluation included amitriptyline indication and total daily dose prescribed.

RESULTS

Of the sample of 2237 patient medical records reviewed, 1732 (77.4%) included amitriptyline prescriptions that were according to the approved STG indications. For the approved STG indications, amitriptyline was prescribed mainly for osteoarthritis (25.8%), neuropathies (18.5%) and chronic non-cancer pain (17.9%). Major depressive disorders constituted only 8.6% of the patient records reviewed; however, doses were atypically low. The main inappropriate indication for amitriptyline was sleep disorders (16%).

CONCLUSION

This MUE has highlighted the need to improve the use of amitriptyline in specific patient populations, e.g. the elderly and patients with sleeping disorders.

No benefit from amitriptyline for chronic low back pain?

DTB commentaries provide an overview of, and commentary on, a clinical trial, systematic review or observational study.

Identification of amitriptyline HCl, flavin adenine dinucleotide, azacitidine and calcitriol as repurposing drugs for influenza A H5N1 virus-induced lung injury

Infection with avian influenza A H5N1 virus results in acute lung injury (ALI) and has a high mortality rate (52.79%) because there are limited therapies available for treatment. Drug repositioning is an economical approach to drug discovery. We developed a method for drug repositioning based on high-throughput RNA sequencing and identified several drugs as potential treatments for avian influenza A H5N1 virus. Using high-throughput RNA sequencing, we identified a total of 1,233 genes differentially expressed in A549 cells upon H5N1 virus infection. Among these candidate genes, 79 drug targets (corresponding to 59 approved drugs) overlapped with the DrugBank target database. Twenty-two of the 41 commercially available small-molecule drugs reduced H5N1-mediated cell death in cultured A549 cells, and fifteen drugs that protected A549 cells when administered both pre- and post-infection were tested in an H5N1-infection mouse model. The results showed significant alleviation of acute lung injury by amitriptyline HCl (an antidepressant drug), flavin adenine dinucleotide (FAD; an ophthalmic agent for vitamin B2 deficiency), azacitidine (an anti-neoplastic drug) and calcitriol (an active form of vitamin D). All four agents significantly reduced the infiltrating cell count and decreased the lung injury score in H5N1 virus-infected mice based on lung histopathology, significantly improved mouse lung edema by reducing the wet-to-dry weight ratio of lung tissue and significantly improved the survival of H5N1 virus-infected mice. This study not only identifies novel potential therapies for influenza H5N1 virus-induced lung injury but also provides a highly effective and economical screening method for repurposing drugs that may be generalizable for the prevention and therapy of other diseases.

Highly pathogenic avian influenza (HPAI) A virus H5N1 causes acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), with mortality as high as 52.79%. No vaccine for HPAI virus is available, and current treatments for influenza A H5N1 virus-induced ALI have limitations. Drug repurposing may be an effective approach for developing novel therapeutic strategies. In this study, we identified 4 drugs, the antidepressant amitriptyline HCl, the ophthalmic flavin adenine dinucleotide, the anti-neoplastic azacitidine and the vitamin D-deficiency treatment calcitriol, as being highly effective for the treatment of H5N1 virus-induced ALI using a transcriptomic-based high-throughput repurposing drug screening. These approved drugs might constitute novel potential remedies for treating influenza H5N1 virus infection, and this screening method may be generalizable for drug repositioning to identify new indications for other diseases.

Experimental and Clinical Pharmacokinetics of Fluoxetine and Amitriptyline: Comparative Analysis and Possible Methods of Extrapolation

The pharmacokinetics of two fluoxetine capsulated dosage forms and two amitriptyline tablet forms after a single oral intake was studied in dogs and healthy volunteers. High significant correlations were detected between plasma concentrations of fluoxetine (r=0.96, p<0.00001, n=11) and amitriptyline (r=0.78, p<0.0224, n=8) in dogs and volunteers. A correlation of medium strength (though insignificant) was detected between nortriptyline concentrations in the plasma of dogs and volunteers (r=0.69, p<0.199, n=5). The bioavailability parameters of the test drugs in dogs and volunteers did not differ. Similar trends of fluoxetine and amitriptyline pharmacokinetic parameters were revealed in volunteers and animals. Methods for extrapolation of experimental pharmacokinetics parameters of fluoxetine and amitriptyline obtained on dogs for humans are proposed and validated.

Effects of 1% amitriptyline gel and mouthwash in patients with periodontal diseases via local drug delivery system: A randomized control clinical trial

Amitriptyline, an agent universally used to treat depression, has an anti-inflammatory activity and a potential for lowering inflammatory mediators. Periodontal diseases like gingivitis and periodontitis if untreated contributes to gingival tissue destruction and bone resorption. These diseases are commonly treated with conventional non-steroidal anti-inflammatory agents and antibiotics along with standard periodontal treatment. The aim of this experimental, observational and randomized clinical control trial was to evaluate the anti-inflammatory effects of amitriptyline on clinical parameters and on inflammatory biomarkers in patients of periodontal diseases by developing 1% oral gel and mouthwash formulations. 30 patients participated in the study were grouped in three categories, patients received standard conventional treatment, patients received gel treatment for four weeks after standard treatment, patients received mouthwash for four weeks after standard periodontal treatment. Results showed that amitriptyline gel and mouthwash in 1% formulation showed promising results by significantly reducing periodontal parameters and inflammatory biomarkers (p<0.001) as compared to standard treatment. Thus, we suggest that gel and mouthwash formulation of amitriptyline is highly efficacious in treating the periodontal diseases.

Limited evidence guides empiric Tx of female chronic pelvic pain

This article reviews the limited evidence for treating chronic pelvic pain and offers recommendations for the primary care physician on providing symptomatic relief in the absence of diagnosed pathology.

The effects of pharmaceuticals on a unionid mussel (Lampsilis siliquoidea): An examination of acute and chronic endpoints of toxicity across life stages

The toxicity and bioconcentration of 3 pharmaceuticals (amitriptyline, iopamidol, and sertraline) were examined using multiple life stages (larval, juvenile, and adult) of the unionid mussel Lampsilis siliquoidea. The endpoints examined varied with life stage but included survival, behavior (algal clearance rate, filtering frequency), and oxidative stress. Iopamidol was not toxic at concentrations up to 101 mg/L. Sertraline was the most toxic chemical (50% lethal concentrations [LC50] and effect concentrations [EC50] = 0.02-0.04 mg/L), but exposure did not induce oxidative stress. Glochidia and juveniles were more sensitive than adult mussels. Algal clearance rate in juvenile mussels was the most sensitive endpoint assessed, similar to or lower than the LC50 values for glochidia. However, the compounds examined were not toxic at concentrations detected in the environment. The relative bioconcentration factors were sertraline > amitriptyline > iopamidol. These results suggest that glochidia toxicity could be a screening tool for rapidly assessing the toxicity of chemicals of concern to freshwater mussels. Environ Toxicol Chem 2017;36:1572-1583. © 2016 SETAC.

Cyclobenzaprine Raises ROS Levels in Leishmania infantum and Reduces Parasite Burden in Infected Mice

BACKGROUND

The leishmanicidal action of tricyclic antidepressants has been studied and evidences have pointed that their action is linked to inhibition of trypanothione reductase, a key enzyme in the redox metabolism of pathogenic trypanosomes. Cyclobenzaprine (CBP) is a tricyclic structurally related to the antidepressant amitriptyline, differing only by the presence of a double bond in the central ring. This paper describes the effect of CBP in experimental visceral leishmaniasis, its inhibitory effect in trypanothione reductase and the potential immunomodulatory activity.

METHODOLOGY/PRINCIPAL FINDINGS

In vitro antileishmanial activity was determined in promastigotes and in L. infantum-infected macrophages. For in vivo studies, L. infantum-infected BALB/c mice were treated with CBP by oral gavage for five days and the parasite load was estimated. Trypanothione reductase activity was assessed in the soluble fraction of promastigotes of L. infantum. For evaluation of cytokines, L. infantum-infected macrophages were co-cultured with BALB/c splenocytes and treated with CBP for 48 h. The supernatant was analyzed for IL-6, IL-10, MCP-1, IFN-γ and TNF-α. CBP demonstrated an IC50 of 14.5±1.1μM and an IC90 of 74.5±1.2 μM in promastigotes and an IC50 of 12.6±1.05 μM and an IC90 of 28.7±1.3 μM in intracellular amastigotes. CBP also reduced the parasite load in L. infantum-infected mice by 40.4±10.3% and 66.7±10.5% in spleen at 24.64 and 49.28 mg/kg, respectively and by 85.6±5.0 and 89.3±4.8% in liver at 24.64 and 49.28mg/kg, after a short-term treatment. CBP inhibited the trypanothione reductase activity with a Ki of 86 ± 7.7 μM and increased the ROS production in promastigotes. CBP inhibited in 53% the production of IL-6 in infected macrophages co-culture.

CONCLUSION/SIGNIFICANCE

To the best of our knowledge, this study is the first report of the in vivo antileishmanial activity of the FDA-approved drug CBP. Modulation of immune response and induction of oxidative stress in parasite seem to contribute to this efficacy.

Interventions for preventing and treating incontinence-associated dermatitis in adults

BACKGROUND

Incontinence-associated dermatitis (IAD) is one of the most common skin problems in adults who are incontinent for urine, stool, or both. In practice, products and procedures are the same for both prevention and treatment of IAD.

OBJECTIVES

The objective of this review was to assess the effectiveness of various products and procedures to preventand treat incontinence-associated dermatitis in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 September 2016). Additionally we searched other electronic databases: CENTRAL(2015, Issue 4), MEDLINE (January 1946 to May Week 3 2015), MEDLINE In-Process (inception to 26 May 2015), CINAHL(December 1981 to 28 May 2015), Web of Science (WoS; inception to 28 May 2015) and handsearched conference proceedings (to June 2015) and the reference lists of relevant articles, and contacted authors and experts in the field.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs, performed in any healthcare setting, with included participants over 18 years of age, with or without IAD. We included trials comparing the (cost) effectiveness of topical skin care products such as skin cleansers, moisturisers, and skin protectants of different compositions and skin care procedures aiming to prevent and treat IAD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-texts, extracted data, and assessed the risk of bias of the included trials.

MAIN RESULTS

We included 13 trials with 1295 participants in a qualitative synthesis. Participants were incontinent for urine, stool, or both, and were residents in a nursing home or were hospitalised.Eleven trials had a small sample size and short follow-up periods. .The overall risk of bias in the included studies was high. The data were not suitable for meta-analysis due to heterogeneity in participant population, skin care products, skin care procedures, outcomes, and measurement tools.Nine trials compared different topical skin care products, including a combination of products. Two trials tested a structured skin care procedure. One trial compared topical skin care products alongside frequencies of application. One trial compared frequencies of application of topical skin care products.We found evidence in two trials, being of low and moderate quality, that soap and water performed poorly in the prevention and treatment of IAD (primary outcomes of this review). The first trial indicated that the use of a skin cleanser might be more effective than the use of soap and water (risk ratio (RR) 0.39, 95% confidence interval (CI) 0.17 to 0.87; low quality evidence). The second trial indicated that a structured skin care procedure, being a washcloth with cleansing, moisturising, and protecting properties, might be more effective than soap and water (RR 0.31, 95% CI 0.12 to 0.79; moderate quality evidence). Findings from the other trials, all being of low to very low quality, suggest that applying a leave-on product (moisturiser, skin protectant, or a combination) might be more effective than not applying a leave-on product. No trial reported on the third primary outcome 'number of participants not satisfied with treatment' or on adverse effects.

AUTHORS' CONCLUSIONS

Little evidence, of very low to moderate quality, exists on the effects of interventions for preventing and treating IAD in adults. Soap and water performed poorly in the prevention and treatment of IAD. Application of leave-on products (moisturisers, skin protectants, or a combination) and avoiding soap seems to be more effective than withholding these products. The performance of leave-on products depends on the combination of ingredients, the overall formulation and the usage (e.g. amount applied). High quality confirmatory trials using standardised, and comparable prevention and treatment regimens in different settings/regions are required. Furthermore, to increase the comparability of trial results, we recommend the development of a core outcome set, including validated measurement tools. The evidence in this review is current up to 28 September 2016.

Drug combinations in diabetic neuropathic pain: an experimental validation

BACKGROUND

Diabetic neuropathy is the most common complication of diabetes mellitus, and the different drug combinations available do not provide effective pain relief. The present study was performed to observe the effect of amitripyline, duloxetine, sitagliptin, and pregabalin, and their combinations on streptozotocin (STZ)-induced diabetic neuropathy.

METHODS

Diabetic neuropathy was induced by STZ, and the tail-flick test was used to assess thermal hyperalgesia before and after (at 30, 60, and 120 min) drug administration. One week after STZ administration, the blood glucose level was observed to be in the diabetic range.

RESULTS

Administration of all the drugs except sitagliptin increased the tail-flick latency significantly as compared to control. Further, the drugs amitriptyline, duloxetine, and pregabalin showed significant pain-relieving effect, when either two of them were administered in combination, although the different combinations had varied degree of pain relief. However, sitagliptin was observed to have no effect when administered alone or in combination with the other three drugs.

CONCLUSIONS

Therefore, the study provides new insights concerning combined therapy of pain, which further needs clinical exploration.

Comparison of paroxetine and amitriptyline in the treatment of refractory globus pharyngeus

BACKGROUND

Clinical trials of antidepressants for treatment of globus are generally rare, let alone for refractory globus pharyngeus.

AIMS

To illustrate the efficacy and side-effects of antidepressants between paroxetine and amitriptyline for refractory globus patients.

METHODS

Refractory globus patients were randomized into paroxetine group; amitriptyline group and lansoprazole group for 6-week treatment. All the subjects were asked to complete the following questionnaires pre- and post-therapy: Glasgow Edinburgh Throat Scale (GETS), Pittsburgh Sleep Quality Index, Hamilton Rating Scale Anxiety/Depression and Medical outcome short-form 36. Treatment response was defined as a >50% reduction in the GETS score.

RESULTS

One hundred and forty-eight patients completed the study. After 6 week treatment, 71.7% of paroxetine group (33/46) were calculated as treatment response, significantly higher than that in amitriptyline group (46.2%, 24/52) and lansoprazole group (14.0%, 7/50). Compared with lansoprazole group or amitriptyline group, a more distinct improvement of emotional well-being, quality of life and quality of sleep were observed in paroxetine group after 6-week treatment.

CONCLUSION

Paroxetine therapy is more efficacious than empirical high-dose antisecretory treatment, or even the low-dose amitriptyline therapy in alleviating globus symptoms, and producing global improvements for refractory globus patients.

Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis

BACKGROUND

Major depressive disorder is one of the most common mental disorders in children and adolescents. However, whether to use pharmacological interventions in this population and which drug should be preferred are still matters of controversy. Consequently, we aimed to compare and rank antidepressants and placebo for major depressive disorder in young people.

METHODS

We did a network meta-analysis to identify both direct and indirect evidence from relevant trials. We searched PubMed, the Cochrane Library, Web of Science, Embase, CINAHL, PsycINFO, LiLACS, regulatory agencies' websites, and international registers for published and unpublished, double-blind randomised controlled trials up to May 31, 2015, for the acute treatment of major depressive disorder in children and adolescents. We included trials of amitriptyline, citalopram, clomipramine, desipramine, duloxetine, escitalopram, fluoxetine, imipramine, mirtazapine, nefazodone, nortriptyline, paroxetine, sertraline, and venlafaxine. Trials recruiting participants with treatment-resistant depression, treatment duration of less than 4 weeks, or an overall sample size of less than ten patients were excluded. We extracted the relevant information from the published reports with a predefined data extraction sheet, and assessed the risk of bias with the Cochrane risk of bias tool. The primary outcomes were efficacy (change in depressive symptoms) and tolerability (discontinuations due to adverse events). We did pair-wise meta-analyses using the random-effects model and then did a random-effects network meta-analysis within a Bayesian framework. We assessed the quality of evidence contributing to each network estimate using the GRADE framework. This study is registered with PROSPERO, number CRD42015016023.

FINDINGS

We deemed 34 trials eligible, including 5260 participants and 14 antidepressant treatments. The quality of evidence was rated as very low in most comparisons. For efficacy, only fluoxetine was statistically significantly more effective than placebo (standardised mean difference -0·51, 95% credible interval [CrI] -0·99 to -0·03). In terms of tolerability, fluoxetine was also better than duloxetine (odds ratio [OR] 0·31, 95% CrI 0·13 to 0·95) and imipramine (0·23, 0·04 to 0·78). Patients given imipramine, venlafaxine, and duloxetine had more discontinuations due to adverse events than did those given placebo (5·49, 1·96 to 20·86; 3·19, 1·01 to 18·70; and 2·80, 1·20 to 9·42, respectively). In terms of heterogeneity, the global I(2) values were 33·21% for efficacy and 0% for tolerability.

INTERPRETATION

When considering the risk-benefit profile of antidepressants in the acute treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents. Fluoxetine is probably the best option to consider when a pharmacological treatment is indicated.

FUNDING

National Basic Research Program of China (973 Program).

Determination of Amitriptyline in the Hair of Psychiatric Patients

A study was conducted on 60 psychiatric patients to evaluate the reliability of a drug-exposure screening test based on gas chromatography/mass spectrometry analysis of hair samples for amitriptyline, and the possibility of using the hair concentrations of amitriptyline to monitor patients' therapeutic compliance. The qualitative test was found to be very reliable (sensitivity 93.3%; specificity 100%; positive and negative predictive values 100 and 93.8%) in assessing the consumer status of patients over a period of 2 months before analysis. Hair levels of amitriptyline ranged from 0 to 17.21 ng mg-1. A significant relationship ( r=0.563; P < 0.002) was found between the hair concentrations and the cumulative intake of amitriptyline over the studied period, but was not judged close enough to estimate one individual's therapeutic compliance. The results are discussed in the light of existing literature.

Cognitive Behavioral Therapy plus Amitriptyline for Children and Adolescents with Chronic Migraine Reduces Headache Days to ≤4 Per Month

OBJECTIVE

The objective of this secondary analysis of results from a previously published trial (Clinical Trials Registration Number: NCT00389038) in chronic migraine in children and adolescents was to examine if participants who received cognitive behavioral therapy and amitriptyline reached a greater level of reduction in headache frequency that no longer indicated a recommendation for preventive treatment as compared to those who received headache education and amitriptyline.

BACKGROUND

Chronic migraine negatively affects children's home, school, and social activities. Preventive medication therapy is suggested for 5 or more headaches per month. Reduction to one headache day per week or less may suggest that preventive treatment is no longer indicated and provide a clinically relevant outcome for treatment efficacy and patient care.

METHODS

Randomized study participants (N = 135) kept a daily record of their headache frequency during 20 weeks of treatment and during a 1 year follow-up period. Baseline headache frequency was determined at the end of a 28 day screening period. Post treatment frequency was determined at 20 weeks (N = 128 completed) and post treatment follow-up was measured 12 months later (N = 124 completed). A chi-square test of independence was conducted by treatment group and by time point to determine group differences in the proportion of headache days experienced.

RESULTS

At 20 weeks (post treatment), 47% of the cognitive behavioral therapy plus amitriptyline group had ≤4 headache days per month compared to 20% of the headache education plus amitriptyline group, (P = .0011), and 32% of the cognitive behavioral therapy plus amitriptyline group had ≤3 headache days per month at 20 weeks compared to 16% of the headache education plus amitriptyline group, (P = .0304). At the month 12 follow-up, 72% of the cognitive behavioral therapy plus amitriptyline group had ≤4 headache days per month compared to 52% of the headache education plus amitriptyline group, (P = .0249), and 61% of the cognitive behavioral therapy plus amitriptyline group had ≤3 headache days per month at their month 12 follow-up compared to 40% of the headache education plus amitriptyline group, (P = .0192).

CONCLUSIONS

Participants who received cognitive behavioral therapy and amitriptyline were more likely than participants who received headache education plus amitriptyline to reach the clinically meaningful outcome of less than or equal to 4 headache days per month at both time points. These results may help inform what treatment outcomes are possible for children and adolescents suffering from chronic migraine and provides further evidence for behavioral treatment to be considered as a key part of a first line treatment regimen.

Randomized, Double-Blind, Crossover Trial of Amitriptyline for Analgesia in Painful HIV-Associated Sensory Neuropathy

We conducted a randomized, double-blind, placebo-controlled, crossover study at a single center in South Africa, to ascertain whether amitriptyline is an effective analgesic for painful HIV-associated sensory neuropathy of moderate to severe intensity in: i) antiretroviral drug naive individuals, and ii) antiretroviral drug users. 124 HIV-infected participants (antiretroviral drug naive = 62, antiretroviral drug users = 62) who met the study criteria for painful HIV-associated sensory neuropathy were randomized to once-daily oral amitriptyline (titrated to a median: interquartile range of 50: 25-50 mg) or placebo for six weeks, followed by a three-week washout period and subsequent treatment crossover. The primary outcome measure was change from baseline in worst pain intensity of the feet (measured by participant self-report using an 11-point numerical pain rating scale) after six weeks of treatment. 122 of 124 participants completed all study visits and were included in the analysis of the primary outcome. In the antiretroviral drug-naive group (n = 61) there was no significant difference in the mean change in pain score from baseline after six weeks of treatment with placebo or amitriptyline [amitriptyline: 2.8 (SD 3.3) vs. placebo: 2.8 (3.4)]. Similarly, there was no significant difference in the change in pain score after six weeks of treatment with placebo or amitriptyline in the antiretroviral drug-user group (n = 61) [amitriptyline: 2.7 (3.3) vs. placebo: 2.1 (2.8)]. Controlling for period effects and treatment order effects did not alter the outcome of the analyses. Nor did analyzing the intention-to-treat cohort (missing data interpolated using baseline observation carried forward) alter the outcome of the analyses. In summary, amitriptyline, at the doses used here, was no more effective than an inactive placebo at reducing pain intensity in individuals with painful HIV-associated sensory neuropathy of moderate to severe intensity, irrespective of whether they were on antiretroviral therapy or not.

TRANSITORY CONSECUTIVE ESOTROPIA AFTER AMITRIPTYLINE TREATMENT FOR NOCTURNAL ENURESIS -CASE REPORT

We report the case of a 9-year-old child operated for intermittent exotropia and V-pattern with a good result 2 months after bilateral Lateral Rectus Muscle Recession. The binocular vision was restored in primary position and down-gaze with excellent stereopsis at near and distance and a deviation of +4 PD in primary position. Three months later, the patient developed a consecutive esotropia of + 18 PD in primary position with diplopia in all gazes triggered by Amitriptyline treatment prescribed one month earlier for nocturnal enuresis. Diplopia was solved in time after anticholinergic medication cessation. During the recovery period, Fresnell prisms have been used in order to eliminate diplopia. Three months after diplopia onset, the binocular vision was restored showing a transitory and reversible effect of the Amitriptyline treatment. Fusion vulnerability can be a possible risk factor in developing diplopia and esotropia in patients treated with anticholinergic drugs.

[Unpredictable chronic mild stress effects on antidepressants activities in forced swim test]

The experiments has been designed to study unpredictable chronic mild stress effect on anti-depressive activities of amitriptyline (10 mg/kg) and fluoxetine (20 mg/kg) in forced swim test in male outbred mice. It is shown that acute treatment with fluoxetine does not produce any antidepressant effects in mice following stress of 14 days while the sub-chronic injections of fluoxetine result in more deep depressive-like behavior. In 28 daily stressed mice, antidepressant effect of fluoxetine is observed independently of the injection rates. Amitriptyline demonstrates the antidepressant activity regardless of the duration of stress or administration scheduling, but at the same time the severity of anti-immobilization effect of amitriptyline in stressed mice is weaker in compare to non-stressed trails. Thus, the injection rates and duration of unpredictable mild chronic stress are the parameters that determine the efficiency of antidepressants in the mouse forced swimming test.

Amitriptyline/Ketamine as therapy for neuropathic pruritus and pain secondary to herpes zoster

Frequent causes of morbidity secondary to herpes zoster include acute pain, secondary infection, and postherpetic neuralgia. A less documented complication is pruritus, which can be either acute or postinfectious when it persists more than 3 months after the rash has healed. We discuss a case of severe, acute neuropathic pruritus and pain secondary to active herpes zoster that was unresponsive to standard medical therapy, including oral antihistamines, topical lidocaine, oral gabapentin, and local wound care. Modest control of the pruritus and pain was achieved with continued multimodal therapy and the addition of topical 2% amitriptyline/0.5% ketamine gel.

Electrocardiograms changes in children with functional gastrointestinal disorders on low dose amitriptyline

AIM: To study the effects of low dose amitriptyline on cardiac conduction in children.

METHODS: Secondary analysis of data obtained from a double-blind, randomized placebo-controlled trial, evaluating low dose amitriptyline in children with a diagnosis of functional abdominal pain, functional dyspepsia, and irritable bowel syndrome according to the Rome II criteria. Children 8-17 years of age were recruited from the pediatric gastroenterology clinics of 6 tertiary care centers in the United States. The electrocardiograms (EKGs) done prior to initiation of amitrityline and 1 mo after initiation of amitriptyline were examined. The changes in cardiac conduction were evaluated in patients and controls.

RESULTS: Thirty children were included in the study. There were 12 patients, ages 9-17 years of both genders, in the amitriptyline treatment group and 18 patients, ages 9-17 years of both genders, in the placebo treatment group. None of the patients had any baseline EKG abnormality. Amitriptyline use was associated with an increase in heart rate (P = 0.024) and QTc interval (P = 0.0107) as compared to pre-EKGs. Children in the placebo group were also noted to present a statistically significant increase in QTc interval (P = 0.0498). None of the patients developed borderline QTc prolongation or long-QT syndrome after they were started on amitriptyline.

CONCLUSION: The study findings suggest that once patients with functional gastrointestinal disorders have been screened for prolonged QTc interval on baseline EKG, they probably do not need a second EKG for reevaluation of cardiac conduction after starting low dose amitriptyline.

Clinical characteristics and medication uses among fibromyalgia patients newly prescribed amitriptyline, duloxetine, gabapentin, or pregabalin

OBJECTIVE

Fibromyalgia is a common chronic pain disorder with unclear etiology. No definitive treatment is available for fibromyalgia, and treatment with antidepressants or antiepileptics is often used for symptom management.

METHODS

Using US health care utilization data, a large population-based cohort study was conducted to describe clinical characteristics and medication use patterns in patients diagnosed with fibromyalgia who newly started amitriptyline, duloxetine, gabapentin, or pregabalin.

RESULTS

There were 13,404 amitriptyline starters, 18,420 duloxetine starters, 23,268 gabapentin starters, and 19,286 pregabalin starters. The mean age ranged from 48–51 years and 72–84% in each group were women. Back pain was the most frequent comorbidity in all 4 groups (range 48–64%) and hypertension, headache, depression, and sleep disorder were also common. The median daily dose at the start of followup was 25 mg for amitriptyline, 60 mg for duloxetine, 300 mg for gabapentin, and 75 mg for pregabalin, and >60% of patients remained on the same dose throughout the follow up period. Only one-fifth of patients continued the treatment started for ≥1 year. The mean number of different prescription drugs at baseline ranged from 8–10 across the groups. More than one-half of patients took opioids and one-third took benzodiazepines, sleep disorder drugs, and muscle relaxants.

CONCLUSION

Patients who started 1 of the 4 common drugs for fibromyalgia similarly had multiple comorbidities and other fibromyalgia-related medication use, but continued the treatment only for a short time. The dose of the 4 drugs was not increased in most patients during the followup period.

Amitriptyline overdose in emergency department of university hospital: evaluation of 250 patients

OBJECTIVE

The purpose of this study was to evaluate the patients with acute amitriptyline poisoning and investigate predictive factors for the development of life-threatening complications.

METHODS

Demographics, clinical, laboratory, and electrocardiographic (ECG) findings of 250 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied.

RESULTS

Median age of patients was 14.6 years, of which, 70% of patients were female and 66% were in pediatric age group. The most common pathological clinical finding and laboratory abnormality were alteration of consciousness and hyponatremia. The rate of convulsive seizure, arrhythmia, and respiratory depression were 17 (6.8%), 16 (6.4%), and 11 (4.4%), respectively. These complications were more seen in pediatric patients than adults (15.8% and 1.2%). The incidence of hyponatremia was more in pediatric patients and severe poisoning groups (38.8 and 53.4%, respectively). The levels of amitriptyline and nortriptyline were significantly higher in the group with complications than the group without complications (p < 0.05). All adult patients were discharged with good prognosis. In pediatric age group, one patient was discharged with severe neurological sequelae and one patient died. QRS duration >100 ms, long corrected QT duration interval, and low Glasgow Coma Score (GCS) at admission were identified as independent risk factors for the development of life-threatening complications (odds ratio: 69.4, 1.9, and 1383, respectively; p < 0.05).

CONCLUSION

Amitriptyline poisoning may be associated with life-threatening complications, especially in pediatric age group and in patients with hyponatremia. Low GCS, presence of hyponatremia, high serum drug levels, and pathological ECG findings on admission may be helpful in predicting the development of complications and poor prognosis.

Effect of low-dose amitriptyline on globus pharyngeus and its side effects

AIM: To compare the efficacy and side effects of low-dose amitriptyline (AMT) with proton pump inhibitor treatment in patients with globus pharyngeus.

METHODS: Thirty-four patients who fulfilled the Rome III criteria for functional esophageal disorders were included in this study. Patients were randomly assigned to receive either 25 mg AMT before bedtime (AMT group) or 40 mg Pantoprazole once daily for 4 wk (conventional group). The main efficacy endpoint was assessed using the Glasgow Edinburgh Throat Scale (GETS). The secondary efficacy endpoints included the Medical Outcomes Study 36-item short form health survey [social functioning (SF)-36] and the Pittsburgh Sleep Quality Index. Treatment response was defined as a > 50% reduction in GETS scores. All patients entering this study recorded side effects at days 1, 8, 15, 22 and 29 using a visual analogue scale.

RESULTS: Thirty patients completed the study. After 4 wk of treatment, the AMT group had a greater response than the conventional group (75% vs 35.7%, P = 0.004). At day 3, the AMT group showed significantly more improvement than the Conventional group in GETS score (3.69 ± 1.14 vs 5.64 ± 1.28, P = 0.000). After 4 wk of treatment, the AMT group showed significantly greater improvement in GETS score and sleep quality than the Conventional group (1.25 ± 1.84 vs 3.79 ± 2.33, 4.19 ± 2.07 vs 8.5 ± 4.97; P < 0.01 for both). Additionally, the AMT group was more likely than the Conventional group to experience improvement in the SF-36, including general health, vitality, social functioning and mental health (P = 0.044, 0.024, 0.049 and 0.005). Dry mouth, sleepiness, dizziness and constipation were the most common side effects.

CONCLUSION: Low-dose AMT is well tolerated and can significantly improve patient symptoms, sleep and quality of life. Thus, low-dose AMT may be an effective treatment for globus pharyngeus.

Lessons learned from hospice care

Pharmaceutical care of the hospice patient offers unique challenges in the management of pain and other symptoms. Lessons learned in providing hospice care can be used in the care of nonterminal patients as well to optimize patient-specific care, regardless of care setting or life expectancy.

Low-dose amitriptyline combined with proton pump inhibitor for functional chest pain

AIM: To investigate the efficacy of amitriptyline with proton pump inhibitor (PPI) for the treatment of functional chest pain (FCP).

METHODS: This was a randomized, open-label trial investigating the addition of low dose amitriptyline (10 mg at bedtime) to a conventional dose of rabeprazole (20 mg/d) (group A, n = 20) vs a double-dose of rabeprazole (20 mg twice daily) (group B, n = 20) for patients with FCP whose symptoms were refractory to PPI. The primary efficacy endpoints were assessed by global symptom score assessment and the total number of individuals with > 50% improvement in their symptom score.

RESULTS: The between-group difference in global symptom scores was statistically significant during the last week of treatment (overall mean difference; 3.75 ± 0.31 vs 4.35 ± 0.29, the between-group difference; P < 0.001). Furthermore, 70.6% of patients in group A had their symptoms improve by > 50%, whereas only 26.3% of patients in group B had a similar treatment response (70.6% vs 26.3%, P = 0.008). Specifically, patients in group A had a significantly greater improvement in the domains of body pain and general health perception than did patients in group B (52.37 ± 17.00 vs 41.32 ± 12.34, P = 0.031 and 47.95 ± 18.58 vs 31.84 ± 16.84, P = 0.01, respectively).

CONCLUSION: Adding amitriptyline to a PPI was more effective than a double-dose of PPI in patients with FCP refractory to a conventional dose of PPI.

Effect of amitriptyline on gastrointestinal function and brain-gut peptides: A double-blind trial

AIM: To study the effects of low-dose amitriptyline (AMT) on gastrointestinal function and brain-gut peptides in healthy Chinese volunteers.

METHODS: This was a double-blind, randomised, placebo-controlled, two-period cross-over trial. Twenty-eight healthy volunteers were randomised and administered 1-wk treatments of AMT (12.5 mg tid) or placebo. Before and during the final two days of treatment, gastric emptying, proximal gastric accommodation and visceral sensitivity were measured by drinking-ultrasonography test; the orocecal transit time (OCTT) was measured by lactulose hydrogen breath test, and fasting blood was collected. Plasma levels of ghrelin, motilin and neuropeptide Y (NPY) were measured by enzyme-linked immunosorbent assay kits.

RESULTS: AMT slowed the OCTT (109.2 ± 29.68 min vs 96.61 ± 23.9 min, P = 0.004) but did not affect liquid gastric emptying and had no effect on proximal gastric accommodation. AMT resulted in decreases in the visual analogue scale (VAS) for difficulty in drinking 600 and 800 mL of water (3.57 ± 0.94 vs 2.98 ± 0.85, 5.57 ± 0.82 vs 4.57 ± 0.98, P < 0.01 for both), although it had no significant effect on the VAS for difficulty in drinking 200 mL and 400 mL of water. AMT significantly increased the plasma ghrelin level (442.87 ± 176.79 pg/mL vs 526.87 ± 158.44 pg/mL, P = 0.04) and the neuropeptide-Y level (890.15 ± 131.46 pg/mL vs 965.64 ± 165.63 pg/mL, P = 0.03), whereas it had no effect on the MTL level.

CONCLUSION: Low-dose AMT could slow OCTT, make the stomach less sensitive and increase the plasma levels of ghrelin and NPY. Thus, we recommend the use of low-dose AMT for functional gastrointestinal disorders.

Displaced dual-mode imaging with desorption electrospray ionization for simultaneous mass spectrometry imaging in both polarities and with several scan modes

Displaced dual-mode imaging (DDI) is introduced as a method for simultaneous imaging in positive and negative-ion mode on the same sample with desorption electrospray ionization imaging, as well as a method for simultaneous imaging in full-scan and tandem mass spectrometry (MS/MS) mode. DDI is performed by using a smaller row distance in the y-direction than the desired image resolution and recording for example every second row in positive-ion mode and the other half of the rows in negative-ion mode, thus resulting in two separate images. This causes some degree of oversampling, which is thus utilized to obtain complementary mass spectrometric of the sample. Imaging with both polarities is exemplified on an imprint of a Hypericum perforatum leaf containing secondary metabolites which ionize in both polarites and a mouse kidney containing phospholipids which ionize in positive or negative mode only. Simultaneous full-scan and MS/MS imaging was demonstrated on the same mouse kidney, as the mouse had been given a relatively low dose of the antidepressive drug amitriptyline. While the full-scan data allowed imaging of the endogenous phospholipids, the drug and its metabolites were only visible in the MS/MS images. The latter approach is useful, for example in whole-body imaging experiments where the full-scan data gives an overview of the tissue, and the MS/MS mode provides the sensitivity to image trace amounts of drugs and metabolites.

Topical amitriptyline combined with ketamine for the treatment of erythromelalgia: a retrospective study of 36 patients at Mayo Clinic

BACKGROUND

Erythromelalgia is an uncommon neurovascular disorder characterized by redness, increased skin temperature, and pain that usually occurs in the extremities. Treatment remains challenging because of its varying response to medical therapy. The objective of this study was to assess the response of erythromelalgia to compounded topical amitriptyline-ketamine.

METHODS

We retrospectively evaluated 36 patients with erythromelalgia who were treated with compounded topical amitriptyline-ketamine from January 1, 2004, through January 31, 2011.

RESULTS

Thirty-two patients (89%) were female. Mean (standard deviation) age was 44.7 (15.8) years (range, 5-74 years). Patients applied the medication 1 to 6 times per day (median, 5 times). One patient (3%) had complete relief from symptoms, 14 (39%) had substantial relief, 12 (33%) had some relief, 7 (19%) had no relief, and 2 (6%) had local worsening of symptoms. No patients had systemic adverse effects.

CONCLUSIONS

A majority of patients with erythromelalgia (75%) reported improvement in pain with topical application of a compounded amitriptyline-ketamine formulation. The medication was well tolerated.

[Intraosseous blocks in the treatment of symmetrical distal diabetic polyneuropathy]

AIM

To evaluate the efficiency of intraosseous blocks (IOB) in the combination treatment of patients with painful diabetic symmetrical distal polyneuropathy (DSDP) of the lower limbs.

SUBJECTS AND METHODS

Seventy-eight patients with painful DSDP were examined. Its diagnosis was verified by neurological examination, assessments of the data of the neuropathic pain diagnostic (DN4) questionnaire and electroneuromyography (ENMG). The pain syndrome was evaluated with a combined visual analogue scale (VAS). The degree of DSDP was estimated using the total symptoms score (TSS) and the neuropathy impairment scale-lower limbs (NIS-LL) scale. The Spielberger questionnaire was used to evaluate reactive and trait anxiety and the Beck inventory was employed to estimate the level of depression. A study group comprised 40 patients receiving IOB as part of the standard treatment. A control group consisted of 38 patients taking oral amitriptyline as a component of the standard treatment. Therapeutic effectiveness was evaluated, by changing the neurological status, trends in VAS, TSS, and NIS-LL scores, and data of psychological questionnaires and ENMG before and after the course of therapy and 1, 3, and 6 months after treatment.

RESULTS

IOB was found to be highly effective in pain syndrome, affective disorders, and other manifestations of DSDP; moreover, the therapeutic effect persisted within 6 months after treatment.

[The combined therapy with valdoxan and amitriptyline of treatment resistant somatized depression]

The combined treatment with valdoxan and amitriptyline has been suggested as one of the possible variants to overcome treatment resistance in somatized depression. A study design was based on the rhythmological model of depression which clinically characterized by altered sleep-awakeness cycles. According to this notion, 36 patients were divided into two groups by the presence (20 patients) or absence (16 patients) of severe sleep disorders. The combined treatment was more effective in the first group of patients with insomnia which was an indicator of altered sleep-awakeness cycles.

Topical amitriptyline-ketamine for treatment of rectal, genital, and perineal pain and discomfort

BACKGROUND

Pain in the rectal, genital, and perineal area is a common condition treated by pain physicians. These chronic pain syndromes are therapeutically challenging because both interventional and drug therapies often are ineffective.

OBJECTIVES

To determine if pelvic pain can be treated effectively with compounded topical amitriptyline-ketamine.

STUDY DESIGN

A retrospective review of medical records.

SETTING

A single academic medical center in the United States.

METHODS

We identified all patients treated with topical amitriptyline-ketamine from January 1, 2004, through November 28, 2011. Medical records were evaluated to determine the diagnosis for which the medication was prescribed. Treatment efficacy and any adverse effects were recorded.

RESULTS

Of the 1,068 patients who received amitriptyline-ketamine, 13 had the medication prescribed for genital, rectal, or perineal pain and had medication efficacy recorded. Of these 13 patients, one (8%) had complete relief, 6 (46%) had substantial relief, 4 (31%) had some relief, and 2 (15%) had no response. One patient reported occasional irritation while using topical amitriptyline-ketamine with lidocaine; no other patients reported local or systemic adverse effects.

LIMITATIONS

Retrospective review; lack of uniform system for pain grading; concurrent use of other medications.

CONCLUSIONS

Topical amitriptyline-ketamine provided a high rate of pain relief with a low adverse-effect burden in patients with pelvic pain. This topical medication could offer an effective, noninvasive, nonopioid therapy for pain in the rectum, perineum, and genitals.

A double-blind, placebo-controlled trial of a topical treatment for chemotherapy-induced peripheral neuropathy: NCCTG trial N06CA

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a troublesome chronic symptom that has no proven pharmacologic treatment. The purpose of this double-blind randomized placebo-controlled trial was to evaluate a novel compounded topical gel for this problem.

METHODS

Patients with CIPN were randomized to baclofen 10 mg, amitriptyline HCL 40 mg, and ketamine 20 mg in a pluronic lecithin organogel (BAK-PLO) versus placebo (PLO) to determine its effect on numbness, tingling, pain, and function. The primary endpoint was the baseline-adjusted sensory subscale of the EORTC QLQ-CIPN20, at 4 weeks.

RESULTS

Data in 208 patients reveal a trend for improvement that is greater in the BAK-PLO arm over placebo in both the sensory (p = 0.053) and motor subscales (p = 0.021). The greatest improvements were related to the symptoms of tingling, cramping, and shooting/burning pain in the hands as well as difficulty in holding a pen. There were no undesirable toxicities associated with the BAK-PLO and no evidence of systemic toxicity.

CONCLUSION

Topical treatment with BAK-PLO appears to somewhat improve symptoms of CIPN. This topical gel was well tolerated, without evident systemic toxicity. Further research is needed with increased doses to better clarify the clinical role of this treatment in CIPN.

Chronic coccydynia in adolescents. A series of 53 patients

BACKGROUND

Little is known about coccydynia in adolescents.

AIM

The aim of this study was to explore causes, clinical and imaging features and response to treatment of chronic coccydynia in adolescents.

DESIGN

This was a cohort study.

SETTING

The study included patients followed up at a specialized consultation in a university hospital.

METHODS

A series of 53 adolescent patients with chronic coccydynia were followed for 1-4 years. Investigations included dynamic X-ray films, with a magnetic resonance imaging scan of the coccyx in 26/53. Treatment was by coccygeal steroid injection or non-steroidal anti-inflammatory drugs (NSAIDs). Amitriptyline or coccygectomy were used as second-line treatment. Outcomes were assessed at a consultation two months after the treatment, then between one to four years later, by telephone interview, questionnaires and by a visual analogue scale (VAS). Fifty-one adult patients with coccydynia formed the control group.

RESULTS

In 20 cases (37.7%) the coccydynia was subsequent to trauma. Obesity was not a risk factor. Abnormal mobility was rarer and spicules more frequent compared to adult patients (P<0.001); 11/27 MRI scans showed a hypersignal within the disc or adjacent bone and 6/27 a hypersignal surrounding the tip of the coccyx (bursitis). Initial treatment was a coccygeal steroid injection for 41 patients and NSAIDs for 12. Ten were given amitriptyline and 3 a coccygectomy. At final assessment, there was no pain or almost no pain in 32/53 (60.4%), moderate pain and functional impairment in 12/53 (22.6%) and severe pain and functional impairment in 9/53 (17%).

CONCLUSION

Coccydynia in adolescents differs from coccydynia in adults. A MRI scan is helpful and should be obligatory for diagnosis. Prognosis is relatively good.

CLINICAL REHABILITATION IMPACT

Our results should help clinicians manage this rare and debilitating condition.

[Anti-inflammatory effects of amitriptyline, diazepam and mebicar using model of acute carrageenan-induced paw edema in rats]

The anti-inflammatory activity of amitriptyline, diazepam and a new, Russian tranquilizer mebicar was studied in a wide range of therapeutic doses on carrageenan-induced paw edema in rats. Mebicar at low doses showed greater and longer (up to 24 h) lasting anti-inflammatory activity as compared to that of amitriptyline and diazepam.

Effects of co-administration of amitriptyline and fluoxetine on inhibitory avoidance in mice

We have previously observed that, while the impairing effects of amitriptyline on inhibitory avoidance in mice are consistently observed, those of acute fluoxetine are negligible. Two experiments were designed to investigate whether a regular dose of fluoxetine potentiates the effect of a low dose of amitriptyline that is ineffective when administered alone. Male and female CD1 mice were administered i.p. 30 min before training, as follows. In the first experiment, they were injected with saline, one of three doses of amitriptyline (2.5, 5, 10mg/kg), one dose of fluoxetine (15 mg/kg), or a combination of amitriptyline (2.5mg/kg) and fluoxetine (15 mg/kg). In the second experiment, the mice were injected with saline, amitriptyline (2.5mg/kg), one of three doses of fluoxetine (10, 15, 20mg/kg), or a combination of 2.5mg/kg of amitriptyline and one of the three mentioned doses of fluoxetine. Drug doses were selected based on previous experiments in our laboratory reported in other publications. The behavioural procedure used to test the effects of these treatments was step-through inhibitory avoidance. The joint administration of amitriptyline 2.5mg/kg and fluoxetine 15 mg/kg had a clear impairing effect on inhibitory avoidance as observed in the two experiments. The dose of 2.5mg/kg of amitriptyline, given alone, was ineffective. Doses of 5mg/kg, or higher, of amitriptyline impaired inhibitory avoidance. The only effect detected when fluoxetine was administered separately was in the males of the experiment 1, which exhibited less avoidance than controls. Our preclinical research throws light on the benefits of the combined administration of antidepressants.

Comparison of safety between individualized and empiric dose regimen of amitriptyline in the treatment of major depressive episode

To accomplish therapeutic goal it is necessary to adjust the dose of medication to be right for every single patient. This procedure of dose adjustment is individualized dose regimen. First of all, pharmacokinetic aspects should be revised, including parameters such as resorption, distribution, metabolism and secretion of drug. For these purposes, the authors developed and clinically assessed the modified Bayesian method supported by original basic computer program. The aim of research was to compare frequency of adverse events in cases of individualized and empiric dose regimens of amitriptyline in the treatment of major depressive episode. Sixty subjects (32- 65 years old), with major depressive disorder (International Classification of Disease, 10th revision), were randomly assigned and single- blinded to take individualized (experimental group, n=30) or empiric (control group, n=30) doses of amitriptyline for 8 weeks. CGI scale and originally designed questionnaire were used for adverse events assessment. In experimental group, 69 complaints on nine different types of adverse effects were recorded during eight-week treatment period. Severe adverse events, such as confusion or arrhythmia, were not registered in this subgroup. In control group, 111 complaints on twelve different types of adverse effects were recorded. Most common were anticholinergic effects, but during the third and fourth week from baseline, some severe adverse events were observed: tremor (16%), fatigue (16%), in one of the subjects confusion occurred and arrhythmia in another. Analyzing of the results according to CGI scale for adverse events showed that, during the treatment period, adverse events were less frequent in experimental group. This was particularly obvious in the first four weeks of treatment, when statistically significant difference (p<0.05) was observed.

The effectiveness of tricyclic antidepressants on lumbar spinal stenosis

Tricyclic antidepressants have not been explicitly studied in the conservative treatment of lumbar spinal stenosis. A retrospective chart review was conducted in a subset of patients with chronic low back pain and lumbar spinal stenosis managed with low dose tricyclic antidepressants. Of 26 patients, 20 reported improvement in back pain. The majority of patients reported improvement with an initial dose of 10 mg of either amitriptyline or nortriptyline and remained on this dose. Patients with both leg and back pain reported improvement in greater proportion than patients with back pain alone. According to this study tricyclic antidepressants appear to be effective in controlling lumbar spinal stenosis symptoms in this patient population. Tricyclic antidepressants need to be further analyzed in randomized controlled studies as a means to conservatively manage lumbar spinal stenosis with stratification based on location of pain.

The role of central mechanisms in the anti-inflammatory effect of amitriptyline on carrageenan-induced paw edema in rats

OBJECTIVE

The present study was designed to further investigate the effect of amitriptyline, a classical tricyclic antidepressant, on carrageenan-induced paw edema in rats.

METHODS

First, amitriptyline was administered intraperitoneally (i.p.) at doses of 20, 40 and 80 mg kg-1, 30 min before subplantar injection of carrageenan. Second, amitriptyline was given intracerebroventriculary or intrathecally at doses of 25, 50 and 100 μg/rat, 30 min prior to carrageenan challenge. Third, the effect of adrenergic receptor antagonists such as propranolol (10 mg kg-1, i.p.), prazosin (4 mg kg-1, i.p.) and yohimbine (10 mg kg-1, i.p.) and an opioid receptor antagonist (naloxone, 4 mg kg-1, i.p.) on the anti-inflammatory effect of amitriptyline (40 mg kg-1, i.p.) was investigated.

RESULTS

Our data confirm that intraperitoneally administered amitriptyline exhibits a marked anti-inflammatory effect on carrageenan-induced paw edema in rats 4 h postcarrageenan challenge (P < 0.001). Intracerebroventricular (i.c.v.) administration of amitriptyline also reduced the development of paw edema at 4 h postcarrageenan (P < 0.001), but intrathecal (i.t.) application of amitriptyline failed to alter the degree of paw swelling. Furthermore, the applied antagonists did not modify the anti-inflammatory effect of amitriptyline.

CONCLUSION

These results support the view that amitriptyline has a considerable anti-inflammatory effect on carrageenan-induced paw edema in rats and suggest that at least a part of this property could be mediated through supraspinal sites. Moreover, it seems unlikely that the investigated adrenergic and opioid receptors have a significant role in this effect of amitriptyline.

The effect of amitriptyline on inhibitory avoidance in mice is dose-dependent

The purpose of the present work was to study the dose-effect relationship of the antidepressant amitriptyline on inhibitory avoidance in male and female mice. Subjects received physiological saline or 2.5, 5, 10 or 20 mg/kg of amitriptyline hydrochloride 30 min before the training phase, and were subjected to the test phase 24 h later. Results showed a clear impairing effect of amitriptyline on inhibitory avoidance in both male and female mice, and that the effect is dose-dependent.

Amitriptyline vs. pregabalin in painful diabetic neuropathy: a randomized double blind clinical trial

AIMS

To compare the efficacy and safety of pregabalin and amitriptyline in alleviating pain associated with diabetic peripheral neuropathy.

METHODS

A randomized, double-blind, crossover, active-control, clinical trial with variable dose titration was carried out (n = 51). Amitriptyline orally, at doses of 10, 25 and 50 mg at night-time and pregabalin orally, at doses of 75, 150 and 300 mg twice daily, by optional titration was used. Each drug treatment was of 5 weeks. There was a placebo washout period for 3 weeks between the two drugs. Assessment for pain relief, overall improvement and adverse events were carried out.

RESULTS

Good, moderate and mild pain relief were noted in 21 (48%), 6 (13%) and 7 (15%) patients on pregabalin and 15 (34%), 5 (11%) and 12 (27%) patients on amitriptyline, respectively, by patient's global assessment of efficacy and safety. Patient and physician's global assessment, McGill pain questionnaire, Likert pain scale and Patient Global Impression of Change showed no significant difference between the treatments, although improvement with both treatments was seen from the first week. Of the 52 adverse events reported, 34 (65.4%) were with amitriptyline, drowsiness being the commonest [in 19 (43%) patients]. Pregabalin caused adverse events in 18 (25%), of which drowsiness was the most common in nine (20%) patients. The preferred pregabalin dose was 150 mg twice daily.

CONCLUSIONS

As there are few differences between the two treatments in efficacy, pregabalin 150 mg twice daily might be the alternative choice as it is associated with fewer adverse effects in our population.