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Amitriptyline ineffective for chronic back pain
Clinical Question
Is low-dose amitriptyline effective for the management of chronic lower back pain?
Bottom line
When compared with a similarly mouth-drying placebo (the anticholinergic benztropine), low-dose amitriptyline provides no greater improvement after 3 months and 6 months of treatment in patients with well-established low back pain. 2b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Outpatient (any)
Synopsis
These researchers recruited (through general advertising) 146 patients with a history of low back pain. The patients had an average of more than 14 years of back pain. Average pain scores at the start of the study were in the mild range (40 to 43 on a scale of 0 to 100) and disability scores were also low (7.5 to 8.2 on a scale of 0 to 23). The patients were randomized, using concealed allocation, to receive either amitriptyline 25 mg or benztropine 1 mg at bedtime. Benztropine causes similar side effects to amitriptyline, but is not known to be effective for low back pain. Analysis was by intention to treat, though there were significant dropouts in both groups (18% to 20%), most due to side effects. At both 3 months and 6 months, average pain and disability scores were decreased in both groups, but neither reduction was clinically significant. There was no significant difference between reports of pain at 3 months or 6 months. Disability scores were better at 3 months in the amitriptyline group but not at 6 months. There was also no difference in patients' global assessment or general health status. The study did not have the power to find a difference if one existed, though the overall improvement, even if different, is not likely to be clinically relevant.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
The investigators conclude:
This trial suggests that amitriptyline may be an effective treatment for chronic low back pain. There were no significant improvements in outcomes at 6 months, but there was a reduction in disability at 3 months, an improvement in pain intensity that was nonsignificant at 6 months, and minimal adverse events reported with a low-dose, modest sample size and active comparator. Although large-scale clinical trials that include dose escalation are needed, it may be worth considering low-dose amitriptyline if the only alternative is an opioid.
Very small sample size
I wonder if this conclusion can be drawn for nortriptyline as well. Good to know at any rate, so we don't waste time with trials of amitriptyline on our back pain patients.
I always thought low dose amitriptyline is helpful for chronic back pain. I already use it for treat some patients.But now I have to change my decision.
Utilisation as one of a combination of interventions for chronic low back pain also should be studied.
We have recently seen reviews showing no efficacy and increased harms to patients with chronic low back pain from both gabapentin drugs and amitriptylene. We should reconsider balanced use of opioids for these suffering patients.
No surprise to all patients who take it and their prescribing physicians. Thought it was used as a sleep -normalizing aid for these patients though, with any pain relief a bonus.
Unfortunately we no idea of the cause or nature of unspecific back and neck pain, Perhaps if patient is depressed should be treated or other medical condition corrected,
After 35 years of practice I know listening to patient with out interrupting you may take short notes then addressing concerns as scientifically as possible (we don,t have good science for chronic pain and patient should know that)
It is important patient with absence pathology on study
self exercises is more effective some time antidepressant helps
good poem
Good for the authors. More dogma bites the dust. Really like the "placebo" approach they used.
Not wholly surprising given that most chronic low back pain is not neuropathic in nature.
I have developed a new way to examine and treat displaced sacroiliac joints with exercises corresponding to the direction of the displacement. I reviewed 180 charts: 16, 9%, had lumbar origin pain. Of the 164 others, 78% left my office with pain relief, of which 83, 50%, had complete pain relief. I am doing a prospective study to find out if they can keep their backs pain-free by doing the exercises at home or by using a pelvic belt. The malrotated sacroiliac joint is the commonest cause of severe low back pain.
Inadequate study all around; should not be considered confirming or refuting benefit of low dose amitriptlyline for this indication.
I would consider low dose…
I would consider low dose amitriptyline before opiod in chronic low back