Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave., Boston, MA, 02215, USA.
Department of Anesthesiology, Mt. Sinai Medical Center of Florida, Miami Beach, FL, USA.
Curr Pain Headache Rep. 2019 Jul 29;23(9):66. doi: 10.1007/s11916-019-0803-z.
While clinicians have been using antidepressants for off-label indications in the treatment of chronic pain in recent years, newer studies have proven effectiveness and provided additional mechanistic understanding and defined potential adverse effects. As depression and chronic pain are frequently comorbid conditions, the use of antidepressants has allowed for treatment of both conditions concomitantly in the same patient population.
The most commonly used antidepressants for chronic pain are tricyclic antidepressants (TCAs), though selective serotonin or noradrenaline reuptake inhibitors and other atypical antidepressants have been shown to be effective at treating chronic pain. In addition to neuropathic pain, bupropion has also demonstrated effectiveness in treating chronic pain caused by inflammatory bowel disease. Selective norepinephrine receptor inhibitors (SNRIs), including duloxetine, serve to suppress neuropathic pain by altering recovery of the noradrenergic descending inhibitory system in the spinal cord. While the direct mechanism of action is largely unknown, TCAs may suppress the noradrenergic descending inhibitory system to produce an antihyperalgesic effect. The use of antidepressants offers alternative and adjunctive therapy options for patients suffering from chronic pain from various modalities. TCAs, mono-amine oxidase inhibitors, selective serotonin receptor inhibitors, SNRIs, and atypical antidepressants have been shown to have analgesic and sometimes antiinflammatory capabilities that are independent of their mood-stabilizing effects. Further studies are warranted to establish better safety profiles and efficacy of antidepressant use in chronic pain.
近年来，临床医生一直在将抗抑郁药用于慢性疼痛的适应证外治疗，但一些新的研究已经证实了其有效性，并提供了更多的机制理解和潜在不良反应的定义。由于抑郁和慢性疼痛常常并存，抗抑郁药的使用允许同时治疗同一患者人群的两种疾病。
用于慢性疼痛的最常用的抗抑郁药是三环类抗抑郁药（TCAs），但选择性 5-羟色胺或去甲肾上腺素再摄取抑制剂和其他非典型抗抑郁药也已被证明对治疗慢性疼痛有效。除了治疗神经病理性疼痛外，安非他酮还被证明对治疗炎症性肠病引起的慢性疼痛有效。选择性去甲肾上腺素受体抑制剂（SNRIs），包括度洛西汀，通过改变脊髓中去甲肾上腺素下行抑制系统的恢复来抑制神经病理性疼痛。虽然其直接作用机制尚不清楚，但 TCA 可能通过抑制去甲肾上腺素下行抑制系统产生抗痛觉过敏作用。抗抑郁药为各种治疗方式引起的慢性疼痛患者提供了替代和辅助治疗选择。TCAs、单胺氧化酶抑制剂、选择性 5-羟色胺受体抑制剂、SNRIs 和非典型抗抑郁药已被证明具有镇痛作用，有时具有独立于其稳定情绪作用的抗炎作用。需要进一步的研究来确定抗抑郁药在慢性疼痛中的更好的安全性和疗效。
