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Antidepressants for treating pain in rheumatological conditions

Issue 25 Synovium (Autumn 2008)

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A systematic review has been carried out of papers published between 1966 and 2007 on the use of antidepressants in rheumatological conditions.1 From the 78 clinical studies and 12 meta-analyses selected, the strongest evidence for the analgesic effect of antidepressants was obtained for fibromyalgia. Moderate relief of symptoms (close to that of standard analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)) was observed for chronic low back pain, while there was no evidence of analgesic effectiveness in rheumatoid arthritis (RA), ankylosing spondylitis (AS) or osteoarthritis (OA). Studies in OA were described as having poor methodological quality, however. It was acknowledged that in RA and AS antidepressants may help with sleep disorders. Independent of antidepressant effect, tricyclic antidepressants (TCAs), even at low doses, were found to be as effective in treating pain as serotonin and noradrenalin reuptake inhibitors (SNRIs), though they are less well tolerated. Selective serotonin reuptake inhibitors (SSRIs) have fewer side-effects than TCAs but higher doses are required to achieve analgesia. It was concluded that the use of antidepressants, particularly TCAs and SNRIs, may be appropriate in the management of conditions such as fibromyalgia and chronic low back pain where standard analgesics and NSAIDs are less effective or poorly tolerated.

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