Tricyclic Antidepressants
37. What are the indications for amitriptyline in A.J.'s treatment regimen?
Tricyclic antidepressants have been used experimentally at low to moderate doses as an adjunct to analgesic pain control. These agents may alter psychological responses to pain, have intrinsic analgesic activity, and may potentiate opioid analgesics.134 European investigations noted an 82% overall response rate to these agents.135 Imipramine (Tofranil) relieved cancer and surgical pain in approximately 75% to 80% of patients, and doxepin (Sinequan) relieved pain completely in approximately half of 16 depressed, patients with chronic pain.136 Tension headaches also were improved with 25 to 100 mg of doxepin.129 Imipramine 50 to 200 mg/day or amitriptyline 10 to 40 mg/day alone or in combination with fluphenazine (Prolixin) have also been investigated for neuropathic pain.137 Neuroleptic agents have fallen out of general use, however, for chronic pain syndromes because of their potential for extrapyramidal syndromes (EPS) and other long-term effects. TCA and methadone combination also have been used successfully for the long-term management of chronic phantom limb pain (see Questions 49 and 51).138 For A.J., the choice of TCA is limited, because of his inability to swallow. A few TCA, however, are available as oral suspensions (doxepin and nortriptyline). Therefore, it would be reasonable to continue A.J.'s present TCA therapy
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