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Care required when prescribing antidepressants for osteoarthritis pain
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Care required when prescribing antidepressants for osteoarthritis pain
Are antidepressants effective and safe for the treatment of symptomatic knee and hip osteoarthritis in adults?
Based on moderate and high‐certainty evidence, although antidepressant use in lower-limb osteoarthritis improves pain, function and quality of life, the degree of improvement is small and not clinically important across the whole population.
However, also based on high‐certainty evidence, the proportion of people achieving a clinically meaningful improvement in pain is higher in people taking antidepressants. This suggests that there may be a subpopulation more likely to respond to this therapy.
Antidepressant use is associated with an increased number of adverse events compared with placebo and consequentially has reduced tolerability. Serious adverse events were present in all trials, but with no preponderance towards either the antidepressants or placebo. Adverse events may limit the use of antidepressants in the community, and patient comorbidities need to be considered.
There were extensive exclusion criteria with regard to comorbid illnesses in the included studies; therefore, participants in the study populations may be healthier overall than those seen in standard clinical practice. This is especially relevant when considering psychiatric conditions.
Pain and depression are linked, with 29 to 86% of people who experience chronic pain having concomitant depression, perhaps through interactions of fatigue, disability and emotional stress. Consequently, the exclusion of people with depression or major psychiatric problems further limits the applicability of the results to this subset of patients.
Although pain is common in osteoarthritis, most people fail to achieve adequate analgesia. Increasing acknowledgement of the contribution of pain sensitisation has resulted in the investigation of medications affecting pain processing with central effects. Antidepressants contribute to pain management in other conditions where pain sensitisation is present.
Leaney AA, et al. Antidepressants for hip and knee osteoarthritis. Cochrane Database Syst Rev 2022;10:CD012157. This review contains 9 trials with a total of 2122 participants.