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Antidepresivi za liječenje neuropatske boli

Abstract

Background

This is an updated version of the original Cochrane review published in Issue 3, 2005 of The Cochrane Library. For many years antidepressant drugs have been used to manage neuropathic pain, and are often the first choice treatment. It is not clear, however, which antidepressant is more effective, what role the newer antidepressants can play in treating neuropathic pain, and what adverse effects are experienced by patients.

Objectives

To determine the analgesic effectiveness and safety of antidepressant drugs in neuropathic pain.

Search methods

Randomised controlled trials (RCTs) of antidepressants in neuropathic pain were identified in MEDLINE (1966 to Oct 2005); EMBASE (1980 to Oct 2005); the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 3, 2005; and the Cochrane Pain, Palliative and Supportive Care Trials Register (May 2002). Additional reports were identified from the reference list of the retrieved papers, and by contacting investigators.

Selection criteria

RCTs reporting the analgesic effects of antidepressant drugs in adult patients, with subjective assessment of pain of neuropathic origin. Studies that included patients with chronic headache and migraine were excluded.

Data collection and analysis

Two review authors agreed the included studies, extracted data, and assessed methodological quality independently. In this update a total of sixty one trials of 20 antidepressants were considered eligible (3293 participants) for inclusion (including 11 additional studies (778 participants)) Relative Risk (RR) and Number‐Needed‐to‐Treat (NNTs) were calculated from dichotomous data for effectiveness and adverse effects.

Main results

Sixty one RCTs were included in total. Tricyclic antidepressants (TCAs) are effective and have an NNT of 3.6 (95% CI 3 to 4.5) RR 2.1 (95% CI 1.8 to 2.5) for the achievement of at least moderate pain relief. There is limited evidence for the effectiveness of the newer SSRIs but no studies of SNRIs were found. Venlafaxine (three studies) has an NNT of 3.1 (95% CI 2.2 to 5.1) RR 2.2 (95% CI 1.5 to 3.1). There were insufficient data to assess effectiveness for other antidepressants such as St Johns Wort and L‐tryptophan. For diabetic neuropathy the NNT for effectiveness was 1.3 (95% CI 1.2 to 1.5) RR 12.4 (95% CI 5.2 to 29.2) (five studies); for postherpetic neuralgia 2.7 (95% CI 2 to 4.1), RR 2.2 (95% CI 1.6 to 3.1) (four studies). There was evidence that TCAs are not effective in HIV‐related neuropathies. The number needed to harm (NNH) for major adverse effects defined as an event leading to withdrawal from a study was 28 (95% CI 17.6 to 68.9) for amitriptyline and 16.2 (95% CI 8 to 436) for venlafaxine. The NNH for minor adverse effects was 6 (95% CI 4.2 to 10.7) for amitriptyline and 9.6 (95% CI 3.5 to 13) for venlafaxine.

Authors' conclusions

This update has provided additional confirmation on the effectiveness of antidepressants for neuropathic pain and has provided new information on another antidepressant ‐ venlafaxine. There is still limited evidence for the role of SSRIs. Whether antidepressants prevent the development of neuropathic pain (pre‐emptive use) is still unclear. Both TCAs and venlafaxine have NNTs of approximately three. This means that for approximately every three patients with neuropathic pain who are treated with either of these antidepressants, one will get at least moderate pain relief. There is evidence to suggest that other antidepressants may be effective but numbers of participants are insufficient to calculate robust NNTs. SSRIs are generally better tolerated by patients and more high quality studies are required.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

Antidepresivi za liječenje neuropatske boli

Niz lijekova koristi se za liječenje depresije (antidepresivi). Za te lijekove pretpostavlja se da su djelotvorni za liječenje boli koja nastaje zbog oštećenja živaca (neuropatska bol). Najmanje trećina pacijenata koji pate od neuropatske boli, a koji su uzeli tradicionalne antidepresive (kao što je amitriptilin) osjeća manju bol. Također postoje dokazi da noviji antidepresiv venlafaksin ima sličnu djelotvornost kao i tradicionalni antidepresivi. Međutim, otprilike petina pacijenata koji su uzeli te lijekove za ublažavanje boli prekinuli su uzimati terapiju zbog nuspojava. Postoje vrlo ograničeni dokazi da neki noviji antidepresivi, poznati kao selektivni inhibitori ponovne pohrane serotonina (SSRI), mogu biti djelotvorni, ali je potrebno više studija da bi se to potvrdilo. Neuropatska bol može se liječiti antidepresivima, a taj učinak ne ovisi o učinku na depresiju.