2017.08.22 04:18
Patients treated with duloxetine for chronic low back pain (CLBP) with multiple painful sites had more benefit than patients with isolated CLBP, and early pain reduction was predictive of response for all patients. This according to a recent post hoc responder analysis of 4 double-blind, randomized, placebo-controlled trials of duloxetine (60 mg/day for 12-14 weeks) in adults patients with CLBP. Primary outcome was proportion of patients with ≥30% reduction in Brief Pain Inventory (BPI) average pain at 12-14 weeks. The proportion of patients with ≥30% and ≥50% (secondary outcome) pain reduction in duloxetine and placebo groups was compared.
Citation:
Alev L, Fujikoshi S, Yoshikawa A, et al. Duloxetine 60 mg for chronic low back pain: post hoc responder analysis of double-blind, placebo-controlled trails. J Pain Res.2017;10:1723-1731. doi:10.2147/JPR.S138297.
Commentary:
CLBP is a challenging problem. Treatment typically includes analgesics such as acetaminophen, NSAIDs, opioids, and adjuvant pain medications, as well as physical modalities including stretching, exercise, and physical therapy. With increased recognition of the side effects of NSAIDs, and risks of addiction with opioids, the use of adjuvant pain medications like duloxetine has become increasingly sigificant. One theory holds that a significant number of patients with CLBP have pain secondary to changes in the central nervous system processing of pain.1,2 For this reason, duloxetine has been studied in double-blind, randomized, placebo-controlled trials of CLBP and has shown positive outcomes.3 If patients who are likely to have central sensitization as an important contributor to their pain can be identified ahead of time, then we might have a higher chance of effectively treating their pain with adjuvant pain medications, including duloxetine. The current post-hoc analysis suggests that patients who have pain in multiple areas may have a higher probability of response to duloxetine than those who have only low back pain, and those who have some response within 2 weeks have a higher chance of long-term response than those who do not respond within a couple of weeks of starting medication. This ability to predict the likelihood of response to duloxetine may be clinically helpful in choosing therapy for this common but difficult to treat condition. —Neil Skolnik, MD
2017.08.22 04:27
2017.08.22 05:51
Antidepessants have been used for chronic pain managements for long times
and amitriptyline(elavil) was other one in gynecology such as vulvodynia.
Many of my patients had been used for these purposes with reaasonably good results.
And also
Duloxetine(cymbalta) was redeveoped as for urinary inconitinence at the tail end of
my practice as a gynecologist. Some of my patients were used as trial basis with
quite satisfactions,but somehow it was not developed in the market as originally hope.
It was too bad to me at that time because I strongly believed it woud be working at that
purpose as well. KJ
2017.08.22 07:15
Thank you, Dr. Hwang, for the comment.
Understanding the cause of any chronic pain or discomfort, I realize, is rather complex.
CNS apparently plays an important role in processing the pain.
Antidepressants have been said to elevate the pain threshold providing some help.
As you said, I have seen a number of patients who are taking Elavil along with other pain killers
per "Pain Control Centers" which are usually run by anesthesiologists.
Duloxetine's brand name is Cymbalta which is antidepressant
and has been in use for control of chronic pain for sometime.
This trial confirms the efficacy of it for some patients.
The study indicates that if the patient doesn't respond during the first few weeks,
it is less likely to be effective in controlling the chronic back pain.
It is interesting to note that the mechanism of relieving pain may have to do
with CNS processing of pain signal.
Any way to avoid the chronic use of NSAIDs and narcotics would be a good news.