What is the best course of action for a patient with chronic pain syndrome on amitriptyline 25mg QPM, with requests to switch from naproxen to meloxicam 7.5mg BID?

From the Guidelines

The patient should continue taking amitriptyline 25 mg QPM for chronic pain syndrome, as it has shown to improve his condition, and the current dose is effective without significant adverse effects beyond manageable constipation, which is being treated with Miralax. The decision to switch from naproxen to meloxicam 7.5 mg BID is reasonable, considering both are NSAIDs, but meloxicam may offer better gastrointestinal tolerability with twice-daily dosing 1. It's essential to note that the CDC guideline for prescribing opioids for chronic pain recommends nonopioid therapy as the preferred treatment for chronic pain, and opioids should only be used when benefits for pain and function are expected to outweigh risks 1. However, in this case, the patient is not taking opioids for chronic pain management, and amitriptyline, an antidepressant, is being used off-label for pain management. The patient's current medication regimen, including benztropine mesylate 2 mg, haloperidol 1 mg, and venlafaxine HCl 150 mg, should be continued as prescribed, and the patient should be monitored for any potential interactions or side effects.

The patient's request to switch from naproxen to meloxicam and continue taking amitriptyline 25 mg QPM along with Miralax packets is reasonable, given the effectiveness of amitriptyline in managing his chronic pain syndrome and the manageable side effect of constipation. The CDC guideline emphasizes the importance of careful consideration of the benefits and risks of treatment options and regular evaluation of benefits and harms of continued therapy 1. In this case, the benefits of continuing amitriptyline 25 mg QPM for chronic pain syndrome outweigh the risks, and the patient should be closely monitored for any changes in his condition or potential side effects.

Key points to consider in this patient's management include:

• Continuing amitriptyline 25 mg QPM for chronic pain syndrome, as it has shown to be effective in improving his condition
• Monitoring for potential interactions or side effects from the patient's current medication regimen
• Regular evaluation of benefits and harms of continued therapy, as recommended by the CDC guideline 1
• Managing constipation with Miralax, as it is a common side effect of amitriptyline and other medications in the patient's regimen.

From the Research

Patient's Current Medication and Request

• The patient is currently taking amitriptyline 25 mg QPM for chronic pain syndrome, benztropine mesylate 2 mg, haloperidol 1 mg, and venlafaxine HCl 150 mg.
• The patient has reported an improvement in their condition since starting amitriptyline 25 mg on 03/25/2025.
• The patient is requesting to switch from naproxen to meloxicam 7.5 mg BID and to continue taking amitriptyline 25 mg QPM along with Miralax packets.

Meloxicam vs Naproxen

• A study published in 1996 2 compared the efficacy and safety of meloxicam 7.5 mg daily and naproxen 750 mg daily in patients with rheumatoid arthritis, and found that meloxicam was better tolerated in the gastrointestinal (GI) tract, with fewer GI adverse events.
• Another study published in 2020 3 discussed the physical characteristics, proprietary and nonproprietary names, methods of preparation, thermal and spectral behavior, methods of analysis, pharmacokinetics, metabolism, excretion, and pharmacology of meloxicam.
• A study published in 1996 4 found that meloxicam had anti-inflammatory effects similar to or better than those of other NSAIDs in animal models, and a greater therapeutic ratio (ulcerogenic potential:efficacy in adjuvant arthritis).

Amitriptyline for Chronic Pain

• A study published in 2012 5 compared the analgesic efficacy of pregabalin, amitriptyline, and duloxetine in patients with chronic diabetic peripheral neuropathic pain, and found that all medications reduced pain when compared with placebo, but no one treatment was superior to any other.

Meloxicam in Juvenile Idiopathic Arthritis

• A study published in 2005 6 evaluated the short-term and long-term efficacy and safety of two different doses of meloxicam compared with naproxen in children with juvenile idiopathic arthritis, and found that the short- and long-term safety and efficacy of meloxicam oral suspension appear to be comparable with the safety and efficacy of naproxen oral suspension.