# Amitriptyline and others



## Guest (Aug 26, 2000)

Having read through a lot of the stuff recently on various websites and also in this bulletin board, I have come across plenty of references to tricyclic anti-depressants such as Amitriptyline and SSRIs such as Paroxetine (Seroxat) being used to alleviate the symptoms of FM. I have just been prescribed Amitriptyline myself (25mg/day)for this purpose. Can anyone help me by explaining why an anti-depressant drug should be used for what seems to be a muscular type problem? I've read in various postings about these drugs aiding sleep. However if this is the main reason for using them, why don't GPs just prescribe ordinary sleeping pills (e.g. Stillnoct)that, generally speaking, don't come with such a heavy parcel of side effects and difficulty in breaking free from at the end of the treatment? Any ideas?One other question.. I know these drugs get different names in different parts of the world just to confuse us. Is Amitriptyline the same drug as Elavil?Hope someone can helpKeeragh


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## squrts (Aug 14, 2000)

yes its the same. fms effects nurotransmitters,in the brain and nervous system,and that what antidepressants work on.dont know the technical stuff,but it kinda makes senice,in my head.


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## Guest (Aug 26, 2000)

Yea, Keer, believe it or not,they even prescribe neurontin for pain with fm and it is a seizure med! But it works wonderful from what I have read. I took elavil 10mg for several months and it did seem to help with my sleep a bit and my pain too. I think you will see some results I hope. What works for one, may not work for the other. Good Luck....


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## penelope (Feb 16, 2005)

I had fibro for years- so painful I really did not want to live. My dr finally talked me into trying nortriptaline(pamelor) 10 mgs at night to start and it was a miracle. W/in days my pain was so much better and in a couple weeks totally gone. Also gone were the other symptoms- feeling unbalanced all the time, blurred vision and skin sensetivity. I now take 40 mgs a day and have felt great for 2 years. No fibro. I don't know how it works, I know it helps my sleep. So maybe that med would work for someone else. Good luckpenelope


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## Guest (Aug 27, 2000)

Thanks for these replies. This is all very encouraging!Keeragh


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## Guest (Aug 27, 2000)

hi..I'm new here but have been reading all the posts...my neurologist explained to me that people who suffer from muscular disorders (fms, cfs,and what I have muscular contractions syndrome *I think its just the newest term they came up with for fybro & CFS mixed)anyay, we do have a sleep disorder in that we do not reach the stage of sleep where the body heals itself..we don't really get much past dream stage and if we do we don't spend enough time in that stage (I think its stage 4?)we aren't in that level long enough for the healing process, therefore leaving us tense, stiff,achy,&so on..so they give meds to in a way trick the brain (this is if your on antidepressants without being "in" a depression)and its supposed to help us relax and sleep..for me the antidpressants were great for 1 month and then it reversed so now I am trying depakote which is really for seizures (which I dont have) but hey if it works I'd eat straw







hope this helps..


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## Guest (Aug 27, 2000)

This all makes good sense and I'm learning plenty by reading the various threads here. What puzzles me about the Anti-depressants is what they've got over ordinary sleeping pills in terms of restorative sleep. I wonder if sleeping pills don't get you to stage 4? Any thoughts on this?K


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## weener (Aug 15, 2000)

Hi Keeragh:I think it has more to do with side effects. I remember at the very beginning of the fm (before I was diagnosed) the doctor gave me some sleeping pills. I would take them at night and I was still groggy by noon the next day. I felt like I was in a fog. I would sit at my typewriter at work and be staring at it. I hated the feeling. I've been on anti-depressants for 6 years now and have never felt groggy when I wake up. Except when I'm having a bad bout of fm.


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## Guest (Aug 28, 2000)

I agree about the side affect issue...what works for one may be disastrous for another...I took trazadone for 1 month and it felt wonderful, I thought a miracle finally happened for me, then WHAM ! I practically had a nervous breakdown due to an allergic reaction to it.(it does take about 30 days to enter completely into the bloodstream tho)..the meds i am now on don't even let me feel like I took an asprin, however, it would stop someone from a seizure or bring someone out of the manic stage of being manic depressive..doesn't make sence how it works...I'm so glad tho that we can all learn from talking to each other..makes me know its not "all in my head"...if I took a sinus pill or a sleeping pill I would be out of it for 2 days atleast ..weird..


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## Guest (Aug 29, 2000)

Hi, am new here, but I agree to side effects of drugs, my bigest one was weight gain from most all antidepressents!! lots and lots of weight!! and I have been on about 20 of the old ones, but they do work best on the FM but I still need something to get to sleep. a_diamondgirl<<<<<<the original night owl!!!!


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## Guest (Aug 30, 2000)

Nortriptyline has been wonderful for me. I've been taking 25mg/day for sleeping for the past 6 years. The bad side effects included weight gain and dry mouth, but the good side effects included diminished fibro pain and ibs symptoms. Before I started on the nortriptyline I had been seeing a physical therapist for a long time to help me with what I thought was a shoulder injury.(at the time I had never heard of fms.) She couldn't understand why my shoulder wasn't getting better with the "help" she was giving me. After I started on the nortriptline for a month of so the shoulder pain went away. I guess our bodies need that stage four sleep to repair itself.


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## penelope (Feb 16, 2005)

Iv'e actually lost weight while being on nortriptaline.Weight gain can be a side effect, but so can weight loss.penelope


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## wanderingstar (Dec 1, 1999)

Amatriptaline is a muscle relaxant and reduces pain perception - which is why it helps muscles, as well as the sleep benefits. I'm gald to see this post as I'm considering switching from Remeron (mirtazapine) to amatriptalyine.


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## Mo (Dec 8, 1999)

I found this information in the British Medical Journal - which is distributed to most Medical Doctors in the UKBMJ 1995;310:386-389 (11 February) Editorials Antidepressants and chronic pain Effective analgesia in neuropathic pain and other syndromes Antidepressants are used widely to treat symptoms other than depression, many of which fit into a general category of pain. They include neuropathic pain (postherpetic neuralgia, diabetic neuropathy (p 827)1), multiple sclerosis, systemic lupus, irritable bowel syndrome, temporomandibular joint dysfunction, atypical facial pain, and fibromyalgia. In Britain no antidepressant is licensed for these indications. Do they work? There is strong evidence from systematic reviews of randomised trials that tricyclic antidepressants are effective treatments for several of these conditions.2 3 4 For established postherpetic neuralgia, tricyclic antidepressants seem to be the only drugs of proved benefit,4 and the number needed to treat to achieve at least 50% pain relief after three to six weeks compared with placebo was 2.3 (95% confidence interval 1.7 to 3.3).2 This means that two patients in five will achieve this (high) level of relief who would not have done so with placebo. Numbers needed to treat of two to three compare well with the most effective analgesics in acute pain, and with anticonvulsants in neuropathic pain.5 Figure 1 shows results from individual randomised trials of diabetic neuropathy and postherpetic neuralgia, each point representing one randomised trial.2 All the points fall in the upper segment, showing treatment to be better than placebo. Overall, about 50-90% of patients can expect to achieve at least 50% pain relief with antidepressants, while others will achieve a lower level of relief that may still be worth while for them. Antidepressants also work in other neuropathic pain syndromes. In 13 randomised studies of diabetic neuropathy the number needed to treat to achieve at least 50% pain relief was 3.0 (2.4 to 4), and in two studies of atypical facial pain it was 2.8 (2.0 to 4.7). The estimated number needed to treat from one study of pain after stroke was 1.7.3 The analgesic effects of antidepressants differ in several ways from classic descriptions of their action on depression itself. Amitriptyline, for example, has proved analgesic efficacy with a median preferred dose of 75 mg (with a clear dose response6 ) in a range of 25-150 mg daily. This range is lower than traditional doses for depression of 150-300 mg. The speed of onset of effect is much faster (one to seven days) than that reported in depression, and the analgesic effect is distinct from any effect on mood.7 The commonest adverse effects are drowsiness and dry mouth, which occur in one in three cases. About one in 30 patients has to stop taking the drug because of intolerable or unmanageable side effects. The profile of adverse effects is the same as when the drugs are used to treat depression. Antidepressants have two roles in managing chronic pain. The primary role is when pain relief with conventional analgesics (from aspirin or paracetamol through to morphine) is inadequate or when pain relief is combined with intolerable or unmanageable adverse effects. The failure of conventional analgesics should justify a therapeutic trial of antidepressants, particularly if the pain is neuropathic (pain in a numb area). There used to be a dogma that the character of the neuropathic pain was predictive of response, so that burning pain should be treated with antidepressants and shooting pain with anticonvulsants. Max showed that this was wrong; in his study both burning and shooting pain responded to tricyclic antidepressants.7 A secondary role of antidepressants in treating chronic pain is their use in addition to conventional analgesics. This can be particularly effective in patients with cancer who have pain in multiple sites, some nociceptive and some neuropathic. Improved sleep is a huge bonus. So which antidepressant should be chosen and at what dose? Tricyclic antidepressants have proved efficacy in chronic pain, but there is little evidence that one drug is better than another, though some patients troubled by adverse effects may benefit from changing drug. The common first choice is amitriptyline, with a starting dose of 25 mg (10 mg in frail patients) to be taken as a single night time dose one hour before lights out. We advise patients to increase the dose by 25 mg at weekly intervals until they either achieve pain relief or adverse effects become problematic. The maximum dose is 150 mg. Patients are warned to expect a dry mouth and drowsiness, which is why they should take the drug at night. If they are still drowsy first thing in the morning they should take the drug earlier in the evening. There is no evidence that the newer antidepressants have greater analgesic effect than tricyclic drugs. The number needed to treat to achieve at least 50% pain relief was five for paroxetine and 15.3 for fluoxetine, while mianserin showed no difference from placebo.1 There is still insufficient evidence from trials to be sure about this. The lower incidence of adverse effects for selective serotonin reuptake inhibitors (fluoxetine and paroxetine) than with tricyclic drugs may make them worth trying for those patients who cannot take tricyclics because of adverse effects. One obvious question is what happens in the long term. Most evidence of efficacy comes from short term trials (lasting weeks to months), and, although many patients continue to achieve pain relief with antidepressants for months to years, this is not true for everybody. Another puzzle is how antidepressants work as analgesics. The standard (but not compelling) explanation is that they act on descending tracts from the brain via noradrenaline and serotonin systems to modulate signalling of pain in the spinal cord. This sounds, and is, an unsatisfactory explanation. But in the meantime it is clear that antidepressants have an important role to play in relieving chronic pain. Henry J McQuay, Clinical reader in pain relief,a R Andrew Moore, Consultant biochemist a a Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe Hospital, The Churchill, Oxford OX3 7LJ 1. Milligan K. Prescribing antidepressants in general practice. BMJ 1997;314:827-8. 2. McQuay HJ, Tramï¿½r M, Nye BA, Carroll D, Wiffen PJ, Moore RA. A systematic review of antidepressants in neuropathic pain. Pain 1996;68:217-27. [Medline] 3. Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain 1992;49:205-19. [Medline] 4. Volmink J, Lancaster T, Gray S, Silagy C. Treatments of postherpetic neuralgia: A systematic review of randomized controlled trials. Fam Pract 1996;13:84-91. [Medline] 5. McQuay H, Carroll D, Jadad AR, Wiffen P, Moore A. Anticonvulsant drugs for management of pain: a systematic review. BMJ 1995;311:1047-52. [Abstract/Full Text] 6. McQuay HJ, Carroll D, Glynn CJ. Dose-response for analgesic effect of amitriptyline in chronic pain. Anaesthesia 1993;48:281-5. [Medline] 7. Max MB, Lynch SA, Muir J, Shoaf SF, Smoller B, Dubner R. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992;326:1250-6. [Medline]


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## wanderingstar (Dec 1, 1999)

Thanks Mo for this great article.


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## Guest (Sep 8, 2000)

Yes, thank you mo, this is a great article, I love this board, its full of helpful, considerate, wonderful people, who can offer an abundance of information. Its fantastic!!!!Lori Ann


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## Guest (Sep 9, 2000)

Many thanks indeed for all these replies. I've learnt more from this message board in the last couple of weeks than I learnt from various GP's I visited over the past 4-5 years!! One other question that has puzzled me... I notice that some members of this board are junior members and some are senior - how does a junior member become a senior one? I can't find anything in the help file about it...


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## wanderingstar (Dec 1, 1999)

Keeragh - it's to do with how many posts you make. You get to a certain number and then you become a senior member. No cachet attached I don't think!


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## Guest (Sep 10, 2000)

Ah... mais oui... of course..thanks


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