Tricyclic antidepressants are an important class of medications that we shouldn’t forget about. They are typically very inexpensive and can provide nice relief for pain syndromes, particularly neuropathy. Treating neuropathy with triple-cyclic antidepressants does take a little paying attention to. Here’s 5 clinical pearls I’m going to think about when recommending these agents.
- Age. The elderly are particularly prone to the anticholinergic side effects of tricyclic antidepressants like amitriptyline and nortriptyline.
- Does the patient have diabetic gastroparesis? Many patients with diabetes may have neuropathy and they also may have gastroparesis. The anticholinergic nature of the TCA’s can lead to exacerbations of gastroparesis.
- Alternative agents. With neuropathy, gabapentin and SNRI’s are two of the other major options. They also have downsides, but overall I would say that utilizing these agents first are typically tried first. Pregabalin can often lead to insurance coverage challenges which will hopefully change over the next couple of years as pregabalin goes generic.
- Insomnia. TCA’s tend to be much more sedating than the SNRI’s. If insomnia is a problem for the patient and/or if symptoms are particularly troublesome at night, it makes some sense that a TCA might be a decent option.
- Constipation. Often patient with diabetes, cardiovascular conditions, and neuropathy are already on several medications and many may already contribute to constipation.
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There is always an option of topical compounded TCA’s with other meds for neuropathy.
Do you have some published evidence regarding the efficacy of compounded topical TCAs?
The proposed mechanism by which tricyclics help with nerve pain is that of duloxetine (i.e norepinephrine mediated) which can be the better choice for certain groups of patients.
If a TCA is warranted don’t forget they are not all created equal. As one example, nortrityline can have a much more favorable side effect profile in the elderly vs amitriptyline (secondary vs tertiary TCA).
Individualized medicine is best