From the Guidelines
Pamelor, a tricyclic antidepressant, is not the first-line treatment for neuropathic pain, but it can be considered as a secondary-amine TCA, with nortriptyline being a suitable option, as stated in the Mayo Clinic Proceedings 1. When considering the use of Pamelor for neuropathic pain, it is essential to follow the steps outlined in the Mayo Clinic Proceedings, which include assessing pain, establishing a diagnosis, and identifying relevant comorbidities 1.
- The typical starting dose for adults is 10-25 mg nightly, which may be gradually increased to 50-150 mg nightly, as tolerated, according to the Journal of the National Comprehensive Cancer Network 1.
- It is crucial to start with a low dose and increase every 3-5 days until tolerated, to minimize adverse effects.
- Common side effects of Pamelor include drowsiness, dry mouth, constipation, blurred vision, and urinary retention, and it may also cause orthostatic hypotension, so patients should rise slowly from sitting or lying positions.
- Pamelor should not be stopped abruptly, as withdrawal symptoms may occur, and dosage should be gradually reduced under medical supervision.
- It should be used cautiously in patients with heart conditions, glaucoma, urinary retention, or seizure disorders, and should not be taken within 14 days of MAO inhibitors due to the risk of serious interactions.
- As stated in the Mayo Clinic Proceedings, cardiac toxicity is a concern, and TCAs should be prescribed with caution in patients with ischemic cardiac disease or ventricular conduction abnormalities, limiting the dosages to less than 100 mg/d when possible, and obtaining a screening electrocardiogram for patients older than 40 years 1.
From the FDA Drug Label
Nortriptyline hydrochloride is indicated for the relief of symptoms of depression. Endogenous depressions are more likely to be alleviated than are other depressive states. The drug Pamelor is another name for nortriptyline, which is used for the relief of symptoms of depression 2.
From the Research
Overview of Pamelor
- Pamelor, also known as nortriptyline, is a tricyclic antidepressant (TCA) used to treat depression and certain types of chronic pain 3.
- TCAs, including Pamelor, are more effective in reducing pain than Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) 3.
Mechanism of Action
- The serotonergic and norepinephrine system play an important role in the comorbidity of pain and depression, and TCAs like Pamelor work by targeting these systems 3.
- Brain structures that codify pain are also involved in mood, and using serotonergic and norepinephrine antidepressants like Pamelor can help mitigate pain 3.
Efficacy in Chronic Pain Management
- A network meta-analysis found that duloxetine, a SNRI, was consistently the highest-ranked antidepressant for chronic pain management, but there is limited evidence for the efficacy of other antidepressants, including Pamelor 4.
- Another study found that TCAs, including Pamelor, are traditionally used to treat chronic pain, but new antidepressants like SNRIs and atypical antidepressants may also be effective 5.
Comparison with Other Antidepressants
- SNRIs, such as venlafaxine, milnacipran, and duloxetine, have differing selectivity for serotonin and norepinephrine reuptake, and may be helpful in relieving chronic pain associated with and independent of depression 6.
- SSRIs and SNRIs have anti-inflammatory effects, which may contribute to their antidepressant action, but the evidence for Pamelor's anti-inflammatory effects is limited 7.