Posted by Philip Burke on November 21, 2007, at 14:04:09
In reply to Neuropathic pain » Philip Burke, posted by kaleidoscope on November 18, 2007, at 15:13:04
> Hi
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> It's interesting that you're taking Remeron and Zoloft since neither of these drugs are generally used to treat neuropathic pain. SSRIs such as Zoloft are considered to be ineffective in the treatment of neuropathic pain whereas Remeron has not been studied for this indication. It is important to bear in mind that although some antidepressants have a clear role in the treatment of neuropathic pain (eg. amitriptyline), others show no efficacy at all.
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> The tricyclic antidepressants are often the most effective drug treatment for neuropathic pain. Amitriptyline (Elavil) is the best established. The usual initial dose is 10 or 25mg at night increasing to 50-75mg. Nortriptyline can be used as an alternative - starting with 10mg at night and increasing up to a usual maximum of 75mg. Nortriptyline is considerably less sedating than amitriptyline and causes a lower incidence of adverse effects overall. Other tricyclic antidepressants such as imipramine and desipramine are also sometimes used to treat neuropathic pain. Desipramine is much less sedating than amitripyline.
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> SSRIs show very little efficacy in the treatment of neuropathic pain and should not generally be prescribed solely for this purpose.
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> Among the newer antidepressants, venlafaxine (Effexor) and duloxetine (Cymbalta) can be effective in the treatment of neuropathic pain, most notably diabetic neuropathy. Duloxetine (Cymbalta) is officially approved for diabetic neuropathic pain. The usual dose is 60mg per day. Effexor and Cymbalta both cause a high incidence of side effects and are much more expensive than tricyclics.
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> Among the antiepileptics, gabapentin (Neurontin) and pregabalin (Lyrica) are similar in effectiveness and have received the most study. Carbamazepine (Tegretol) may also be effective, although it is not as well proven. If necessary, the dose of pregabalin can be increased up to a maximum of 600mg per day in two or three divided doses. Side effects are dose-dependent.
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> Tramadol, a weak opioid with additional properties, has shown effectiveness in the treatment of certain types of neuropathic pain. Tramadol can be tried before considering potent opioids.
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> I was taking the synthetic opiate Ultram ER 300 mg. (tramadol), the maximum dose, for about 3 months with mirtazapine, 30 mg. at bedtime. It help reduce the neuropathic pain considerably, but I began to have insomnia, headaches and increased sweating. I was told by others I looked "red in the face". Just by chance, I took my blood pressure at my pharmacy in one of those set ups for the public. It read 148/118. Since I am a trained First Responder and have a sphygmomanometer and stethoscope, I took my BP again at home and found the same high BP. Typically, my BP is ~128/86. I found a PDR, looked up Ultram and found that the most common side effects are an increase in BP and insomnia AND I read that it should be prescribed with caution if an antidepressant is being taken. I stopped it immediately and went through a week of hellish withdrawal. Curiously, the withdrawal symptoms were almost exclusively mental - dysphoria, difficulty concentrating, anergia and fatigue. My BP dropped to a more normal reading of ~118/78, the headaches stopped and I stopped having trouble getting to sleep. I caution anyone who is considering taking Ultram while taking an antidepressant, especially one that potentiates both seratonin and norepineprine in synaptic transmission. I thought that I had found the best and safest painkiller for my neuropathy, but obviously not.I have found that Remeron helps with pain. It is a tetracyclic, potentiates both seratonin and norepinephrine and does not have the troublesome anticholinergic side effects of the tricyclics. But, I have gained over 25 lbs since I started taking it, something you do not want to do when you have polyneuropathy due to "failed back surgery syndrome" (discectomy X 2 @ L4-5). Which antidepressant can help my neuropathic pain, does not cause weight gain and other bothersome side effects, and also is effective in treating my unipolar affective mood disorder? I am having a very difficult time trying to find out. I tried Cymbalta twice, over 6 weeks on 60 mgs. each time, but felt absolutely awful. Every doctor I have been to recommends Cymbalta, but I cannot take it.
The pain I experience is radicular, due to nerve damage from nerve root compression at L3-4-5, but seems to respond to the type of drug therapy that is used for diabetic neuropathy. Paroxetine and sertraline have been shown to be somewhat effective in diabetic neuropathy, and therefore I have found these drugs to help my condition. I was taking MSContin, 30 mg. every 12 hours, with mirtazapine. Paroxetine was added, and after about 2 weeks my pain decreased and I was able to decrease the MSContin 50%.
I take 100 mgs. of Lyrica three times daily and find it very helpful. I find it better than Neurontin due to its longer half-life.
Apparently, save for Wellbutrin, practically every antidepressant I have looked into can cause weight gain. In most cases, though, it is not clear whether it is due to the drug, or to the syndrome of depressive illness. Has anyone out there LOST weight after taking a particular antidepressant other than Wellbutrin? I am looking for one that will help with pain, not make me gain weight, and is effective in relieving the symptoms of depression.
I am hopeful that with the right antidepressant, at the best dosage, along with the Lyrica, I can go without taking a powerful painkiller. The trick is finding the drugs with side effects that are tolerable.
poster:Philip Burke
thread:795592
URL: http://www.dr-bob.org/babble/20071115/msgs/796382.html