Adv Urol. 2009;2009:797031. Epub 2010 Feb 14.
Antidepressant drugs for chronic urological pelvic pain: an evidence-based review.
Papandreou C, Skapinakis P, Giannakis D, Sofikitis N, Mavreas V.
Postgraduate Program in the Management of Pain, University of Ioannina School of Medicine, Greece.
The use of antidepressant drugs for the management of chronic pelvic pain has been supported in the past. This study aimed to evaluate the available evidence for the efficacy and acceptability of antidepressant drugs in the management of urological chronic pelvic pain. Studies were selected through a comprehensive literature search. We included all types of study designs due to the limited evidence. Studies were classified into levels of evidence according to their design. Ten studies were included with a total of 360 patients. Amitriptyline, sertraline, duloxetine, nortriptyline, and citalopram are the antidepressants that have been reported in the literature. Only four randomized controlled trials (RCTs) were identified (two for amitriptyline and two for sertraline) with mixed results. We conclude that the use of antidepressants for the management of chronic urological pelvic pain is not adequately supported by methodologically sound RCTs. From the existing studies amitriptyline may be effective in interstitial cystitis but publication bias should be considered as an alternative explanation. All drugs were generally well tolerated with no serious events reported.
PMID: 20169141 [PubMed - in process]
PMCID: PMC2821755
Antidepressants and UCPPS
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Antidepressants and UCPPS
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Re: Antidepressants and UCPPS
Editorial - Antidepressant drugs for chronic urological pelvic pain: An evidence-based review
Written by Philip M. Hanno, MD
Friday, 23 April 2010
BERKELEY, CA (UroToday.com) - Need For Further Studies Regarding Use of Antidepressants for Chronic Urologic Pelvic Pain
The analgesic properties of antidepressant drugs were first reported 40 years ago. They are now widely used for the treatment of chronic and neuropathic pain. Their efficacy has now been shown in randomized controlled trials (RCTs), systematic reviews and meta-analyses. Much remains to be learned about their efficacy in chronic pain.
Christos Papandreou and colleagues from Ioannina, Greece recently published a comprehensive evidence-based review of the literature in an effort to assess the available evidence for the efficacy and acceptability of antidepressant drugs in chronic urological pelvic pain. They note that antidepressants may be effective either by acting directly on the neural mechanisms of pain or by reducing depressive symptoms that may influence the experience of pain or the capacity to cope with the pain. While epidemiological studies of chronic pain have shown the strong association between depressive symptoms and experience of pain in general and chronic pelvic pain in particular, evidence suggests their analgesic effect seems to be independent of their antidepressant effect. Studies have shown that the spinal and neuronal pathways are modulated by activation and/or inhibition of neurons in the periphery, at spinal levels and at supraspinal regulatory sites. Serotonergic pathways and receptor mechanisms play a crucial role within this neuronal network. The antidepressants alleviate symptoms probably via mechanisms such as blockade of acetylcholine receptors, inhibition of reuptake of released serotonin and norepinephrine, and blockade of the histamine H1 receptor.
The authors categorized the level of evidence for each paper they reviewed based upon guidelines developed by the Agency for Healthcare Research and Quality. Level 1 evidence (meta-analysis of RCTs) was not found and level 5 evidence (case reports) were not included. This left level 2, 3, and 4 evidence: RCTs, non RCT trials, and retrospective case series respectively. They included 10 studies in their review for analysis, 5 on amitriptyline, 2 on sertraline, and 1 each on nortriptyline, duloxetine, and citalopram.
The main finding of this review is that the use of antidepressants in the management of chronic urologic pelvic pain is not as yet supported by an adequate number of well-designed clinical trials. Whether it ever will be, with the majority of medications now available in generic form, is doubtful. Amitriptyline was found to be effective compared with placebo in interstitial cystitis, but only one reported trial was an RCT. Two amitriptyline studies were of longer duration and showed that long-term use may be well tolerated. Papandreou and co-workers conclude that antidepressants are generally safe drugs with tolerable side effects. The withdrawal rates in most studies were not high and the reported reasons for the withdrawal were not relevant to the side effects.
Antidepressants are safe generally tolerable drugs and may have a place in the treatment of chronic urological pelvic pain. Amitriptyline, in particular, may be useful in the management of interstitial cystitis. Further research is necessary. The authors suggest that carefully designed placebo-controlled double blind studies of longer duration with larger numbers of patients suffering from chronic urological pelvic pain are needed. Their suggestion to stratify the sample with respect to the presence or absence of major depression seems a valid one. The large, multicenter study RCT from the National Institute of Diabetes and Digestive and Kidney Diseases on the use of amitriptyline for interstitial cystitis should be published in the spring, and will provide much needed data, though it must be kept in mind that it did not compare amitriptyline alone to placebo, but rather behavioral modification and conservative treatment strategies in treatment naïve patients with either amitriptyline or a placebo, thus potentially masking some of the drug effect.
Papandreou C, Skapinakis P, Giannakis D, Sofikitis N, Mavreas V
Adv Urol. 2009;2009:797031.
doi: 10.1155/2009/797031
PubMed Abstract
PMID: 20169141
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Re: Antidepressants and UCPPS
A recent study has linked the use of TCAs (tricyclic antidepressants like Elavil aka amitriptyline) to cardiovascular disease.
http://pubmed.ncbi.nlm.nih.gov/21118851
This suggests you should not use it at high doses for long periods, especially if you have a history of heart/circulation problems. To quote Dr Hanno:
http://pubmed.ncbi.nlm.nih.gov/21118851
This suggests you should not use it at high doses for long periods, especially if you have a history of heart/circulation problems. To quote Dr Hanno:
For interstitial cystitis/bladder pain syndrome, tricyclic antidepressants are generally used in doses much lower than those used for depression. However, this article confirms that we must be cautious in using this class of medication in patients with baseline significant cardiovascular disease, and that when symptoms go into remission, it is reasonable to taper and stop these medications to avoid unnecessary risk.
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