Topical Tricyclic Antidepressants

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Few classes of drugs are more extensively used in the management of chronic pain conditions than the tricyclic antidepressants (TCAs). Substantial and convincing evidence supports their use in a variety of pain conditions including neuropathic pain and the pain associated with fibromyalgia. Their use is so common that it is now normal for them to be initiated by General Practitioners. The pain relief that may be apparent is independent of their antidepressant effects but any mood improvement that may occur is often welcome. In addition to pain reduction and mood improvement, muscle relaxation and normalization of sleep pattern may also occur. All oral TCA used for a pain indication is "off label."

Despite the widespread use of this class of drug in pain management, they are far from universally effective. Even when pain relief does occur, it is often partial. Indeed one would be more certain of an improvement in sleep with TCA use than pain reduction. Among the side effects associated with oral TCA use are:

• Sleepiness

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