Little Help, Possible Harm of Antidepressants for Musculoske
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Back pain and osteoarthritis (OA) are leading causes of disability. It has been estimated that back pain affects about 7.3% of the global population and that neck pain affects about 5.0%. OA-related hip and knee symptoms affect 12% of the population.

Antidepressants are frequently prescribed for pain, particularly chronic pain. About 75% of clinical practice guidelines endorse antidepressants for low back pain, as do two recently published OA guidelines, the investigators note.

The American College of Physicians recommends the SNRI duloxetine for low back pain, and the Osteoarthritis Research Society International and the American College of Rheumatology recommend duloxetine for pain management.

To determine the efficacy of these agents for pain, the investigators conducted a comprehensive literature search for randomized controlled trials that compared any antidepressant with placebo for patients with neck or low back pain with or without radicular symptoms, as well as for patients with hip or knee OA, or both.

The analysis included 33 trials with 5318 participants. Most trials (84.9%) had a parallel-group design. The others had a crossover design with washout periods ranging from 1 to 2 weeks. All but one trial reported data from participants with chronic pain.

Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less but not at 3-13 weeks. Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less but did at 3-13 weeks and 3-12 months. Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks and disability due to osteoarthritis at two weeks or less, with low certainty evidence at 3-13 weeks. TCAs and other antidepressants did not reduce pain or disability from back pain.

Overall, it can be concluded that results of a systematic review and meta-analysis show that SNRIs or TCAs had little or no effect on back pain, sciatica, or OA. In addition, SNRIs were associated with a significantly increased risk for adverse events (AEs).

Source:
https://www.bmj.com/content/372/bmj.m4825
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