Tricyclic antidepressants and anticonvulsants

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Tricyclic antidepressants are effective in relieving neuropathic pain. There are no significant differences in efficacy between the different tricyclic antidepressants, though unfortunately, side effects often limit their use. While the evidence for venlafaxine is less strong, its use can be justified, particularly in patients with both neuropathic pain and low mood. There is a lack of high level evidence of the efficacy of selective serotonin reuptake inhibitors (SSRIs) for treating neuropathic pain.

The anticonvulsants carbamazepine, phenytoin, sodium valproate, clonazepam, gabapentin, and pregabalin are effective in treating neuropathic pain. Benefit is independent of the characteristics of the pain. Gabapentin and pregabalin are licensed for treatment of neuropathic pain.

There is no measurable difference in the analgesic benefit of the two drug classes (tricyclic antidepressants or anticonvulsants) in neuropathic pain or in the number of patients needed to treat before a minor or major adverse effect occurs. Gabapentin and pregabalin, however, can have fewer side effects in many patients, though systematic examination of this is awaited in patients with cancer pain.

Patients with neuropathic pain should have a trial of a tricyclic antidepressant or venlafaxine or an anticonvulsant. The choice of drug should be based on relative contraindications, possible drug interactions, and risk of side effects for each patient. Antidepressants and anticonvulsants may occasionally be prescribed simultaneously, though it is good clinical practice to introduce only one drug at a time.

Common adjuvant analgesics for cancer pain

Drugs

Indications

Non-steroidal anti

Bone pain

inflammatory drugs

Soft tissue infiltration Hepatomegaly

Corticosteroids

Raised intracranial pressure Soft tissue infiltration Nerve compression Hepatomegaly

Antidepressants Anticonvulsants Antiarrhythmics

Nerve compression or infiltration Paraneoplastic neuropathies

Bisphosphonates

Bone pain

Fear, anxiety, sleep, punishment, autonomic changes

Location and intensity

Fear, anxiety, sleep, punishment, autonomic changes

Limbic system Parabrachial

Location and intensity

Cortex

Attention

Dorsal columns

Lamina I

Lamina I

Lamina V

Thalamus

The brain can talk back to the spinal cord

Peripheral mechanisms and spinal inputs

Motor activation/autonomic

Integration of pain and emotion at higher centres. With permission from Professor A. Dickenson

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