Anti-Depressants and Fibromyalgia

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  Anti-depressants and fibromyalgia go hand in hand for many patients. Antidepressants is a broad term used to describe a class of drugs commonly used to treat depression, anxiety, mood disorders, bipolar disorder, and other mental health problems. They work by increasing the body’s production of chemicals known as neurotransmitters. These chemicals transmit nerve signals within the brain. There are four main classes of antidepressants: tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and serotonin and norepinephrine reuptake inhibitors (SNRIs). The following text provides an overview of each class and offers specific details about selected antidepressants within each class.

 Tricyclic Anti-Depressants

  Tricyclic antidepressants were among the first antidepressants used to treat depressive disorders. They work primarily by blocking the absorption (reuptake) of two specific neurotransmitters: norepinephrine and serotonin. By doing so, they make these chemicals more available within the brain, which allows brain cells to better communicate with each other and improve mood.

 Examples of common TCAs include: amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), nortriptyline (Pamelor), and imipramine (Tofranil). Although TCAs are effective for many people, they have a tendency to cause a considerable number of side effects and are therefore typically not used as a first line of treatment.

Common side effects include dry mouth, vision disturbances, increased fatigue, low blood pressure, drowsiness, weight gain, tremors, constipation, bladder problems, daytime sleepiness, increased heart rate, sensitivity to sunlight, and sexual problems such as delayed orgasm and low sex drive (particularly in men). Some TCAs are more likely to cause specific side effects than others. For example, Norpramin is more likely to cause sleepiness, while Elavil is more likely to cause weight gain. Furthermore, high doses of TCAs may result in health problems, therefore some patients may require blood tests on occasion to check their blood levels of the TCA they are taking. In addition, TCAs can impact blood sugar levels, therefore diabetic patients should closely monitor their blood sugar levels when taking a TCA. Individuals with narrow-angle glaucoma, an enlarged prostate, cardiac problems, thyroid problems, or a history of seizures should also discuss TCAs carefully with their doctor to determine if they are safe to use.

Monoamine Oxidase Inhibitors

 Monoamine oxidase inhibitors were the first type of antidepressant developed. The enzyme monoamine oxidase typically works to remove the neurotransmitters norepinephrine, serotonin, and dopamine from the brain. MAOIs work by preventing this from occurring and thereby increasing the amount of these neurotransmitters. Unfortunately, MAOIs interact with substances in many foods and beverages, as well as a considerable number of other medications. Patients who take MAOIs must also adhere to strict diets and medication regimens. Therefore, MAOIs are usually used only as a “last resort” when other antidepressant medications have not worked. Common examples of MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), selegiline (Emsam, Zelapar), and isocarboxazid (Marplan).

 Side effects can be serious and include daytime sleepiness, dizziness, low blood pressure, diarrhea, disturbances in taste, nervousness, muscle aches, insomnia, weight gain, decreased libido, erectile dysfunction, urinary difficulty, tingling sensations in the skin, headache, racing heartbeat, chest pain, neck stiffness, nausea, and vomiting. Certain foods that contain high levels of the chemical tyramine – including cheeses, pickled foods, meats, beer, and wine – must also be avoided to prevent dangerously high blood pressure from occurring. Certain medications must also be avoided while taking MAOIs in order to avoid potentially serious adverse reactions. These include other antidepressants, certain pain medications, decongestants, and some herbal supplements.

Selective Serotonin Reuptake Inhibitors

  Selective serotonin reuptake inhibitors are a new class of antidepressants, and are often the first line of treatment for many patients with depression. SSRIs work by blocking the absorption of serotonin in the brain, making the neurotransmitter more available to brain cells. Some of the most common examples of SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), and citalopram (Celexa). Some SSRIs, such as Paxil, are available in what is known as extended-release or controlled-release form, designated by the letters XR or CR following the drug name. These forms of SSRIs offer controlled release of the drug over the course of a day or longer with one single dose.

Since all SSRIs work in a similar manner, they tend to cause the same side effects, more or less. Common side effects associated with the use of SSRIs include dizziness, headache, nausea, insomnia, nervousness or restlessness, dry mouth, diarrhea, rash, increased sweating, weight gain, and drowsiness. In addition, sexual side effects are common for both women and men. Women may experience failure to achieve orgasm while men may experience erectile dysfunction and delayed ejaculation. It is also important to use caution when taking blood thinning medications – such as aspirin, nonsteroidal anti-inflammatory drugs (Aleve), or anticoagulants (Coumadin) – as concurrent use of these medications while taking an SSRI may increase the risk of bleeding.

Serotonin and Norepinephrine Reuptake Inhibitors

  In a manner similar to that of SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs) increase the availability of the neurotransmitters serotonin and norepinephrine in the brain.

 Common examples of SNRIs include venlafaxine (Effexor), mirtazapine (Remeron), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and milnacipran (Savella). Effexor is available in an extended-release version, as are several others. Currently, Cymbalta is the only FDA approved antidepressant to treat fibromyalgia.

Common side effects of SNRIs are similar to those of other antidepressants and include drowsiness, vision disturbances, feeling lightheaded, strange dreams, constipation, fever and/or chills, headache, changes in appetite, tremors, dry mouth, heart palpitations, difficulty urinating, agitation or anxiety, insomnia, muscle weakness, and nausea. Nausea is particularly common with Cymbalta, whereas extended-release forms of SNRIs do not tend to cause nausea as frequently. Effexor, when taken at high doses, can raise blood pressure. Similar to SSRIs, SNRIs may also interfere with blood thinning medications such as Coumadin and aspirin. Finally, Cymbalta may also make pre-existing liver problems worse therefore individuals with liver disease may require periodic blood tests to check liver function.

General Precautions Regarding Antidepressant Use

  The U.S. Food and Drug Administration (FDA) requires that all antidepressants have a warning label to indicate that children, adolescents, and young adults may have an increased risk of suicide when taking antidepressants. Therefore, anyone who takes an antidepressant – regardless of type – should be closely monitored for changes in mood (i.e., worsening depression) or unusual behaviors. These changes are most commonly seen in the first few weeks after starting an antidepressant. It is important to understand, however, that over the long run, antidepressants are more likely to reduce the risk of suicide by improving an individual’s mood.

It is also important for individuals taking antidepressants to tell their doctor about any other medications and dietary supplements they are taking, as some antidepressants can interact adversely with other drugs and cause dangerous adverse reactions. Certain antidepressants may also harm an unborn child if taken during pregnancy, or be transmitted to an infant through breast milk. Women who are taking an antidepressant and who are contemplating pregnancy should talk to their doctor about the potential risks associated with continuing its use while pregnant.

 On rare occasions, antidepressants can cause extremely high levels of serotonin in the brain – a condition known as serotonin syndrome. This usually occurs when two medications that raise serotonin are taken at the same time. This may include other antidepressants, other medications, as well as the herbal supplements St. John’s Wort and 5-HTP. Symptoms associated with serotonin syndrome include confusion, irregular heartbeat, dilated pupils, fever, and loss of consciousness. Individuals who are taking antidepressants along with another serotonin-increasing medication should seek medical assistance immediately if they experience these signs or symptoms.

  Finally, although antidepressants are not considered to be addictive, many individuals may experience a phenomenon known as discontinuation syndrome if they abruptly stop treatment or miss several doses of their medication. Symptoms of discontinuation syndrome are withdrawal-like in nature and include nausea, headache, dizziness, lethargy, and flu-like symptoms. Because of this, antidepressants should be gradually tapered off when use of these medications is no longer needed.

Choosing the Best Option for You

  While each individual class of antidepressant works in more or less the same manner, specific antidepressants have individual properties that may make them more appropriate for use in one person over another. For example, individuals with low energy may do better with a more energizing SSRI such as Prozac; however, others who tend to be more anxious may fare better with an SSRI that helps to improve anxiety, such as Paxil. Among SNRIs, Effexor is often a good choice to try in patients whose depression has not improved with the use of other medications, whereas Cymbalta may also ease chronic pain in addition to improving symptoms of depression. Because of their considerable side effects, TCAs and MAOIs are not usually tried as treatments methods until all other options have been exhausted.

  While each individual class of antidepressant works in more or less the same manner, specific antidepressants have individual properties that may make them more appropriate for use in one person over another. For example, individuals with low energy may do better with a more energizing SSRI such as Prozac; however, others who tend to be more anxious may fare better with an SSRI that helps to improve anxiety, such as Paxil. Among SNRIs, Effexor is often a good choice to try in patients whose depression has not improved with the use of other medications, whereas Cymbalta may also ease chronic pain in addition to improving symptoms of depression. Because of their considerable side effects, TCAs and MAOIs are not usually tried as treatments methods until all other options have been exhausted.

Antidepressant Use with Fibromyalgia

 Anti-Depressants and Fibromyalgia have a long history together. An estimated 30% of all fibromyalgia patients have major depression at the time they are diagnosed, and as many as 20% have generalized anxiety disorder. Having to deal with the chronic pain. fatigue and tenderness associated with fibromyalgia may play a role in the development of depression for fibromyalgia sufferers. In addition, the role of depression may also have a genetic link in fibromyalgia. Many individuals who have both depression and fibromyalgia also have a family history of depression, and some researchers have suggested that perhaps both depression and chronic pain involve genes that are involved in pain transmission and signaling. Depression is clearly a major playing in causal relationships and negative feedback loops associated with Fibromyalgia.

  Due to the frequent occurrence of depression and anxiety in patients with fibromyalgia, antidepressant therapy is often initiated to help ease patients’ symptoms. Furthermore, anecdotal and clinical research has shown that antidepressant use by fibromyalgia patients can actually improve pain, fatigue, and sleep problems, along with depression. TCAs – particularly amitriptyline – have historically been the most commonly used group of antidepressants to treat the symptoms associated with fibromyalgia, and they have demonstrated effectiveness in treating both pain and depression. However, their use is often limited due to side effects. Because of the limited tolerability of TCAs, a number of SNRIs, SSRIs, and MAOIs have been investigated to determine their effectiveness in treating fibromyalgia. Research suggests that SNRIs may be of greater benefit than SSRIs or MAOIs in treating persistent fibromyalgia pain (Arnold, 2007; Moret & Briley, 2006). Currently, Cymbalta (an SNRI) is the only antidepressant that is FDA-approved to treat fibromyalgia.

  In a comprehensive review published in the prestigious Journal of the American Medical Association, Häuser and colleagues evaluated 18 randomized placebo-controlled trials (the “gold standard” for research study design) to determine the effectiveness of TCAs, SSRIs, SNRIs, and MAOIs when used by fibromyalgia patients. In total, data on 1,427 patients was reviewed. The authors found a strong association with the use of antidepressants and a reduction in pain, fatigue, depressed mood, and sleep disturbances. In addition, there was also strong evidence to support an association between antidepressant use and improved quality of life. In terms of pain reduction, however, the greatest improvements were found with the use of TCAs, followed by MAOIs. The smallest reductions in pain were seen among patients who used SSRIs or SNRIs.

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References

1.        Maletic V, Raison CL. Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci. 2009;14:5291-5338.

2.        Häuser W, Bernardy K, Uceyler N, Sommer C. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009;301(2):198-209.

3.        Arnold LM. Duloxetine and other antidepressants in the treatment of patients with fibromyalgia. Pain Med. 2007;8:S63-S74.

4.      Moret C, Briley M. Antidepressants in the treatment of fibromyalgia. Neruopsychiatr Dis Treat. 2006;2(4):537-548.

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