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150 mg hs

Abbreviations: hs, at bedtime; TCAs, tricyclic antidepressants. Source: From American Pain Society, 2008.

Abbreviations: hs, at bedtime; TCAs, tricyclic antidepressants. Source: From American Pain Society, 2008.

Tricyclic Antidepressants

The TCAs were, at one time, considered to be the first line for treating neuropathic pain, such as postherpetic neuralgia or postmas-tectomy pain syndromes. Currently, they have fallen to lower down on the option list as newer and better medications with fewer side effects have been developed. They are not recommended for older patients, because they have the potential for orthostatic hypotension (American Geriatric Society [AGS], 2009).

The starting doses are low and start at 10—25 mg titrated up to 150 mg per day (APS, 2008; Wallace & Staats, 2005). Escalating to higher doses in an effort to obtain an additive effect for pain relief should take place every 3—7 days (Chen, Lamer, Rho, Marshall, Sitzman, Ghazi & Brewer, 2004). The pain management doses are lower than the antidepressant doses of 150—30 mg per day. Of note, the pain relief action of these medications is i ndependent of any effect on mood (Lynch & Watson, 2006).

A meta-analysis of the TCA medications indicates that TCAs are effective for use in treating neuropathic pain (APS, 2003). Elavil (amitriptyline) is the best known and most studied among the TCAs (APS, 2003). It is also a primary recommendation for the treatment of fibromyalgia pain (D'Arcy & McCarberg, 2005). Analgesic response is usually seen within 5—7 days (APS, 2008). Adverse effects for TCAS include:

Constipation

■ Urinary retention

■ Orthostatic hypotension

■ Anticholinergic side effects

■ Caution in patients with heart disease, symptomatic prostatic hypertrophy, neurogenic bladder, dementia, or narrow angle glaucoma

■ Increased suicide behavior in young adults (Institute for Clinical System Improvement [ICSI], 2007)

These side effects make the medications undesirable for use in the elderly population of patients, especially when they are used in combination with opioid analgesics.

Additionally, TCAs can increase the risk of cardiac arrhythmias in patients with underlying conduction abnormalities. Caution is advised with the use of desipramine in children because of anecdotal reports of sudden death (APS, 2003). Although these drugs are cheap and readily available, they do have some very significant adverse effects. At the opposite end of the spectrum, they also have the best profile for use in treating neuropathic pain conditions. However, each patient being considered for TCAs should have a thorough assessment for any risk factors, such as cardiac conduction abnormalities. When starting TCA therapy, the current recommendation is to screen all patients older than 40 years with an electrocardiogram (ECG) to evaluate the patients for conduction abnormalities (APS, 2008).

The TCA medications are not recommended for use in elderly patients, because of the high incidence of undesirable side effects and the potential for increased fall risk related to early morning orthostatic hypotension (AGS, 2002, 2009; Lynch & Watson, 2006). The biggest benefits of using TCAs for pain relief are improved sleep (Wilson, Caplan, Connis, Gilbert, Grigsby, Haddox, Simon, 1997) and the relief of neuropathic pain—pain that is described by patients as burning, shooting, or painful numbness.

When caring for a patient who is taking TCAs as adjuvant pain medication, health care providers should be aware of the potential for early morning orthostatic hypotension and caution the patient to sit on the side of the bed before trying to stand. Some patients complain of sleepiness with these medications and, if this is problematic, the patient should be instructed to take the medication earlier in the evening rather than at bedtime to decrease the early morning sedation that can be experienced. For elderly men, urinary retention can be problematic and urinary status should be carefully checked. For the dry mouth associated with TCA use, hard candies or gum can ease the dry feeling.

Patients should always be told the rationale for prescribing an antidepressant medication for pain, so they are comfortable with taking the medication. The onset of analgesic effect may take up to 2 weeks, and patients should be encouraged to extend a trial of these medications to this period to see if analgesia occurs.

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