Tricyclic and tetracyclic antidepressants for low back pain

Examples

Tricyclic antidepressants

Generic Name	Brand Name
amitriptyline hydrochloride	Elavil
desipramine	Norpramin
doxepin hydrochloride	Sinequan
imipramine hydrochloride	Tofranil
nortriptyline	Aventyl, Norventyl

Tetracyclic antidepressants

Generic Name
maprotiline

How It Works

Low doses of tricyclic or tetracyclic antidepressant medicine increase the level of certain brain chemicals, which may affect how the brain perceives pain. They may also help you sleep.

Why It Is Used

Low doses of antidepressants are often used to treat people who have chronic pain.

Higher doses of antidepressants are used to relieve depression.

When these drugs are not used

• Some of these medicines are not given to older adults, because the medicines cause too many severe side effects.
• Cyclic antidepressants usually are not given to people with certain heart problems, such as irregular heartbeats or low blood pressure.

How Well It Works

Research has shown that cyclic antidepressants reduce chronic low back pain for some people.^{1, 2} They are not recommended for sudden and severe (acute) low back pain. Other antidepressants called selective serotonin reuptake inhibitors (SSRIs) do not appear to help people with low back pain.²

Side Effects

Side effects may vary among these medications, and most of them decrease as the person continues to take the medication. Cyclic antidepressants tend to have more common and more serious side effects than other, newer types of antidepressant medicines, such as serotonin reuptake inhibitors (SSRIs). Side effects include:

• Stomach upset and other digestive problems, such as constipation.
• Dry mouth.
• Blurred vision.
• Lowered blood pressure.
• Weight gain.
• Tremors and sweating.
• Inability to urinate (urinary retention).
• Sexual side effects.
• Confusion or delirium in older adults.
• Fatigue and drowsiness.

Advisories. Health Canada and the U.S. Food and Drug Administration (FDA) have issued advisories on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when the doses are changed.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

These medicines need to be started at low doses, and the dose should be increased gradually to reduce the severity of side effects. Your doctor may recommend occasional blood tests to check the amount of the medication in your blood. Too much of this type of medicine in the bloodstream can be dangerous.

Do not suddenly stop taking these medicines without talking to your doctor. These medicines are often gradually tapered off with supervision from your doctor.

These medicines may take a few weeks to start working, especially in older adults. Desipramine and nortriptyline have the fewest side effects and may be given to older adults for this reason. However, these medications may not be the preferred choice for older adults, due to severe side effects.

Tricyclic antidepressants (TCAs) and tetracyclic medications are used in carefully selected people who are closely monitored while they are taking the medicine. These antidepressants are not generally used along with:

• Certain heart medicines, such as digoxin (Lanoxin).
• Certain medicines used to treat seizures, such as phenytoin (Dilantin).

Cyclic antidepressants are not recommended for people who have serious heart conditions.

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Author:	Douglas Dana Shannon Erstad, MBA/MPH	Last Updated: April 3, 2006
Medical Review:	William M. Green, MD - Emergency Medicine Tom Bailey, MD - Family Medicine Kathie Hummel-Berry, PT, PhD - Physical Therapy Robert B. Keller, MD - Orthopedics
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