Rheumatology Advance Access published online on November 6, 2008
Rheumatology, doi:10.1093/rheumatology/ken420
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Comment on: Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies: reply
1Service de Médecine Interne et Thérapeutique, Hôtel Dieu, Université Paris Descartes, Paris, 2Service de Rhumatologie, Hôpital Hautepierre, Strasbourg, 3Service de Rhumatologie, Hôpital Henri Mondor, Créteil and 4Centre d’Evaluation et de Traitement de la Douleur, Hôpital St Antoine, Paris, France
Correspondence to:
S. Perrot, Service de Médecine Interne et Thérapeutique, Consultation de la Douleur, Hotel Dieu, 1 Place du Parvis Notre Dame, 7500 Paris, France. E-mail: serge.perrot{at}htd.aphp.fr
SIR, We thank Dr Fontenele and colleagues [1] for their interesting comments on our recent article [2] and on a recent review on amitriptyline [3]. In fact, our results were in accordance with those reported by Nishishinya and colleagues [3] and our conclusions are also consistent with those of another recent review on anti-depressants in fibromyalgia (FMS) [4]. We confirm that amitryptiline demonstrates analgesic effects at low doses (25–50 mg) in FMS, without any improvement of these effects at higher doses, and no dose-related effects. However, there are no published trials comparing tricyclic anti-depressants (TCAs) and newer anti-depressants like serotonin and norepinephrine reuptake inhibitors (SNRIs). Most trials on amitriptyline in FMS are not as long as trials with SNRIs, with the exception of that reported by Carette et al. [5], and the methodological quality of the trials is weaker, as studies are not so recent. Other drugs like cyclobenzaprine (structurally similar to amitriptyline, differing by only one double bond) have also demonstrated interesting effects in FMS [6]. Thus, the use of TCAs should not be discouraged in FMS treatment, in the face of an absence of long-term efficacy and an excess of adverse events, as declared by Fontenele and colleagues [1]. Indeed, studies not only directly comparing SNRIs with TCAs but also those making a comparison with anti-convulsants are now mandatory, to establish a rational algorithm for the pharmacological treatment of FMS.
Disclosure statement: The authors have declared no conflicts of interest.
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- Fontenele JB, Leal LKAM, Felix FHC. Comment on: Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies & Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology (2008) 47. doi: 10.1093/rheumatology/ken419.
- Perrot S, Javier RM, Marty M, Le Jeunne C, Laroche F. Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies. Rheumatology (2008) 47:1117–23.
[Abstract/Free Full Text] - Nishishinya B, Urrútia G, Walitt B, et al. Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology. Advance Access published August 12, 2008, doi:10.1093/rheumatology/ken317.
- Uçeyler N, Häuser W, Sommer C. A systematic review on the effectiveness of treatment with antidepressants in fibromyalgia syndrome. Arthritis Rheum (2008) 59:1279–98.[CrossRef][Web of Science][Medline]
- Carette S, Bell MJ, Reynolds WJ, et al. Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia. A randomized, double-blind clinical trial. Arthritis Rheum (1994) 37:32–40.[Web of Science][Medline]
- Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with cyclobenzaprine: a meta-analysis. Arthritis Rheum (2004) 51:9–13.[CrossRef][Web of Science][Medline]
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