Richeimer S H, Bajwa Z H, Kahraman S S, Ransil B J, Warfield C A
Department of Anesthesiology, School of Medicine, University of California-Davis 95817, USA.
Clin J Pain. 1997 Dec;13(4):324-9. doi: 10.1097/00002508-199712000-00010.
Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial?
A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patient's age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders.
Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline.
Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.
三环类抗抑郁药（TCA）已被证明可用于缓解各种神经性疼痛和头痛疼痛综合征，无论患者是否伴有抑郁症。慢性疼痛患者中抑郁症的发病率很高，因此三环类抗抑郁药特别适合慢性疼痛患者。我们希望研究美国马萨诸塞州波士顿贝斯以色列医院疼痛管理中心三环类抗抑郁药的使用模式，主要是为了回答四个问题：（1）所有患者中接受三环类抗抑郁药治疗的比例是多少？（2）每种抗抑郁药治疗了多少患者，每种抗抑郁药的剂量范围是多少？（3）三环类抗抑郁药对慢性疼痛是否有益，这种反应是否取决于特定剂量？（4）患者是否接受了充分的三环类抗抑郁药试验，哪些因素导致三环类抗抑郁药试验中断？
按字母顺序对1145份疼痛门诊患者病历进行了回顾。共确定282例患者接受了三环类抗抑郁药治疗。从这282份病历中获取了有关患者年龄、诊断、三环类抗抑郁药使用情况和剂量、其他疼痛治疗方法、治疗反应及副作用的数据。如有可能，记录现有的抑郁症诊断。当使用相当于50毫克或更少阿米替林的剂量时，三环类抗抑郁药剂量被定义为低剂量；当使用相当于至少150毫克阿米替林的剂量时，被定义为全剂量。治疗反应记录为轻度、中度或显著改善。报告轻度改善的患者被视为无反应者。
在1145例患者中，282例接受了三环类抗抑郁药治疗。共有205例（73%）患者接受低剂量治疗，仅34例（12%）接受全剂量治疗。其余43例（15%）接受中等剂量治疗。阿米替林是最常用的药物（58%）。阿米替林和多塞平似乎比其他三环类抗抑郁药更有效。31例同时患有抑郁症的患者对我们治疗的反应率与未记录有抑郁症的患者相似。在仅使用三环类抗抑郁药作为治疗方法的患者中，仅存在全剂量治疗反应更大的趋势。就导致药物剂量受限或停药的副作用而言，氯米帕明、阿米替林和多塞平似乎比丙咪嗪、地昔帕明和去甲替林更严重。
在转诊至多学科疼痛中心的患者中，25%使用了三环类抗抑郁药，且通常使用低至中等剂量，即使在既无副作用也无最佳临床反应的情况下也是如此。
