Tools for Practice Outils pour la pratique


#375 Pharm for Fibro: Can antidepressants ease the pain?


CLINICAL QUESTION
QUESTION CLINIQUE
 Do antidepressants reduce pain in patients with fibromyalgia?

BOTTOM LINE
RÉSULTAT FINAL
 In patients with fibromyalgia, meaningful pain reduction (~30% reduction in pain) occurs in ~50% of patients on duloxetine or mirtazapine versus 35% on placebo over 7-14 weeks. SSRIs and amitriptyline are also likely effective based on limited evidence. Compared to placebo, antidepressants do not increase the risk of withdrawing from treatment due to adverse effects, with the exception of high-dose duloxetine.


CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

 Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session


EVIDENCE
DONNÉES PROBANTES
  • Seven systematic reviews of randomized, placebo-controlled trials (RCTs) in the last 10 years. Ages 42-53, >90% women. Statistically significant unless indicated.
  • Duloxetine: 4 systematic reviews (6-7 RCTs, 2249-2642 patients).1-4 At 8-27 weeks:
    • Proportion of patients with ≥30% reduction in pain:1 48% versus 36%, number needed to treat (NNT)=9.
      • 30mg versus placebo: No difference.2
      • 60-120mg: ~50% versus 35% (placebo).2
    • Proportion with >50% reduction in pain:1 34% versus 23%, NNT=9.
    • Withdrawal due to adverse events: No difference.1
      • Exception: 120mg dose; 21% versus 11% (placebo), number needed to harm=10.
    • Adverse effects: include nausea (26%), constipation (15%), headache (14%) versus 4-8% placebo; hyperhidrosis 8% versus 1% placebo.1
    • Other reviews found similar.2-4
  • Mirtazapine: One systematic review (3 RCTs, 591 patients, average 30mg daily).5 At 7-14 weeks:
    • >30% pain reduction: 47% versus 34% (placebo), NNT=8.
    • ≥ 50% pain reduction: No difference.
    • Adverse event withdrawals: No difference.
    • Adverse effects include:
      • Somnolence: 41% versus 14% (placebo).
      • Any weight gain: 19% versus 1% (placebo).
  • SSRIs (fluoxetine, citalopram, paroxetine): One systematic review (7 RCTs, 383 patients).6 At 6-16 weeks:
    • ≥30% reduction in pain: 33% versus 23% (placebo), NNT=10.
    • Adverse event withdrawals: no difference.
  • Amitriptyline: One systematic review (4 RCTs, 275 patients, 25-50mg daily).7 At 8-24 weeks:
    • >50% pain reduction: 36% versus 11%, NNT=5.
    • Adverse event withdrawals and adverse events: No difference.
  • Limitations: Minimal reporting of patient function,1-3,5-8 small studies of short duration,6,7 majority industry funded,2,3,5 blinding uncertain.5
CONTEXT
CONTEXTE
  • Diagnosis requires chronic diffuse pain >3 months.8
    • Specific tender point distribution no longer needed.8
    • Specialist diagnosis/treatment or extensive investigations not required.8
  • Exercise and cognitive behavioural therapy can improve pain and mobility.9
  • 90-day cost:10 Duloxetine 60mg ~$100; mirtazapine 30mg ~$35.

Erin Beattie October 22, 2024

Helpful re mirtazepine and pain effects

peter entwistle October 24, 2024

informative

Anita Augustine October 25, 2024

A great tool

Latest Tools for Practice
Derniers outils pour la pratique
program image
Jennifer Potter MD CCFP

#376 Testosterone supplementation for men: Let’s (andro-)pause for a moment (Update)

What are the benefits and harms of testosterone supplementation in healthy men or those with age-related low testosterone?
Read Lire 0.25 credits available Crédits disponibles
program image
Betsy Thomas BScPharm

#375 Pharm for Fibro: Can antidepressants ease the pain?

Do antidepressants reduce pain in patients with fibromyalgia?
Read Lire 0.25 credits available Crédits disponibles
program image
Émélie Braschi MD PhD

#374 Vitamin D and Fracture Prevention: Not what it’s cracked up to be?

Does vitamin D prevent fragility fractures?
Read Lire 0.25 credits available Crédits disponibles
October 15, 2024

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session
Author(s)
Auteur(s)
  • Jennifer Young MD CCFP-EM
  • Danielle Perry MSc RN
  • Betsy Thomas BScPharm

1. Lian YN, Wang Y, Zhang Y et al. Int J Neurosci. 2020 Jan; 130(1):71-82.

2. Lunn MP, Hughes RA, Wiffen PJ. Cochrane Database Syst Rev. 2014 Jan 3; 2014(1):CD007115.

3. Welsch P, Üçeyler N, Klose P et al. Cochrane Database Syst Rev. 2018 Feb 28; 2(2):CD010292.

4. Migliorini F, Maffulli N, Eschweiler J, et al. J Orthop Surg Res. 2023 Jul 17; 18(1):504.

5. Welsch P, Bernardy K, Derry S et al. Cochrane Database Syst Rev. 2018 Aug 6; 8(8):CD012708.

6. Walitt B, Urrútia G, Nishishinya MB et al. Cochrane Database Syst Rev. 2015 Jun 5; 2015(6):CD011735.

7. Moore RA, Derry S, Aldington D et al. Cochrane Database Syst Rev. 2019 May 28; 5(7):CD011824.

8. Fitzcharles MA, Ste-Marie PA, Goldenberg DL et al. Pain Res Manag. 2013 May-Jun; 18(3):119-26.

9. Bidonde J, Fisher E, Perrot S et al. Semin Arthritis Rheum. 2023 Dec; 63:152248.

10. Price Comparison of Commonly Prescribed Pharmaceuticals in Alberta. Available at: https://pricingdoc.acfp.ca/. Accessed September 25, 2024.

Authors do not have any conflicts of interest to declare.