What are the alternatives to amitriptyline (tricyclic antidepressant) for treating radicular pain?

From the Guidelines

Duloxetine (60mg daily) is a recommended alternative to amitriptyline for treating radicular pain, as it has been associated with lower pain intensity and improved function in patients with chronic low back pain, as shown in a systematic review for an American College of Physicians clinical practice guideline 1. Several alternatives to amitriptyline for treating radicular pain include:

• Gabapentinoids, such as gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) and pregabalin (starting at 75mg twice daily, increasing to 300-600mg daily), which work by modulating calcium channels to reduce nerve excitability
• SNRIs, such as duloxetine (60-120mg daily), which inhibit pain signals by increasing serotonin and norepinephrine levels
• Other anticonvulsants, such as carbamazepine (200-1200mg daily) or oxcarbazepine (600-1800mg daily)
• Topical treatments, such as lidocaine patches (5%) or capsaicin cream, which can provide localized relief with fewer systemic side effects
• Non-pharmacological approaches, such as physical therapy, cognitive behavioral therapy, and nerve blocks, which may also be beneficial Treatment should be individualized based on comorbidities, potential side effects, and drug interactions, and patients should be monitored for efficacy and tolerability over 4-8 weeks before considering alternatives 1. Key considerations when selecting an alternative to amitriptyline include:
• Efficacy: duloxetine has been shown to be effective in reducing pain intensity and improving function in patients with chronic low back pain 1
• Safety: gabapentinoids and SNRIs are generally well-tolerated, but may have adverse effects such as nausea, dizziness, and somnolence 1
• Drug interactions: patients should be monitored for potential interactions with other medications, such as antidepressants, anticonvulsants, and opioids 1

From the FDA Drug Label

The efficacy of duloxetine delayed-release capsules in chronic low back pain (CLBP) in adults was assessed in two double-blind, placebo-controlled, randomized clinical trials of 13-weeks duration (Studies CLBP-1 and CLBP-2), and one of 12-weeks duration (CLBP-3) Studies CLBP-1 and CLBP-3 demonstrated efficacy of duloxetine delayed-release capsules in the treatment of CLBP. Patients in all trials had no signs of radiculopathy or spinal stenosis.

Alternatives to Amitriptyline for Radicular Pain:

• Duloxetine: may be considered as an alternative for treating radicular pain, although the studies specifically excluded patients with radiculopathy.
• Pregabalin: is used to treat neuropathic pain associated with spinal cord injury, which may be considered as an alternative for radicular pain.

Note: These alternatives are based on the provided drug labels and may not be directly indicated for radicular pain. 2 3

From the Research

Alternatives to Amitriptyline for Radicular Pain

• Other tricyclic antidepressants like nortriptyline can be used as alternatives to amitriptyline for treating radicular pain, as seen in a study where nortriptyline and/or gabapentin plus physical therapies were used to treat cervical radicular pain 4.
• Gabapentin is another option that can be used in combination with other treatments for radicular pain, as shown in a study where gabapentin was used in combination with nortriptyline and physical therapies 4.
• Topical formulations such as a combination of diclofenac, ibuprofen, baclofen, cyclobenzaprine, bupivacaine, gabapentin, and pentoxifylline can be used to treat radicular pain, as reported in a case series where three patients with cervical and/or lumbosacral radicular pain experienced subjective improvement in radicular pain, function, and sleep 5.
• Epidural corticosteroid injections can be used to reduce leg pain and disability at short-term follow-up in people with lumbosacral radicular pain, as found in a systematic review of 25 clinical trials 6.

Considerations for Alternative Treatments

• The efficacy of alternative treatments may vary depending on the individual patient and the specific condition being treated.
• The use of alternative treatments should be based on the best available evidence and should be tailored to the individual patient's needs and preferences.
• Patients should be informed of the potential benefits and risks of alternative treatments and should be involved in the decision-making process.

Evidence for Alternative Treatments

• The evidence for alternative treatments for radicular pain is limited, and more research is needed to fully understand their efficacy and safety.
• A systematic review of amitriptyline for neuropathic pain found that there was no first-tier or second-tier evidence for its use in treating any neuropathic pain condition, and that the evidence was of very low quality 7.
• A study on epidural corticosteroid injections found that they were probably slightly more effective compared to placebo in reducing leg pain and disability at short-term follow-up, but the treatment effects were small and may not be considered clinically important by patients and clinicians 6.