How do snris work for pain

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Duloxetine 60 mg once-daily in the treatment of painful physical symptoms in patients with major depressive disorder. J Psychiatr Res. Duloxetine, 60 mg once daily, for major depressive disorder: a randomized double-blind placebo-controlled trial.

Duloxetine in the treatment of depression: a double-blind placebo-controlled comparison with paroxetine. J Clin Psychopharmacol. The outcome of physical symptoms with treatment of depression. J Gen Intern Med. Efficacy of venlafaxine for the long term treatment of chronic pain with associated major depressive disorder.

Am J Ther. Schmader KE. Epidemiology and impact on quality of life of postherpetic neuralgia and painful diabetic neuropathy. Bowsher D. The lifetime occurrence of Herpes zoster and prevalence of postherpetic neuralgia: a retrospective survey in an elderly population. Eur J Pain. Pharmacologic management of neuropathic pain: evidence-based recommendations. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.

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A double-blind, randomized multicenter trial comparing duloxetine with placebo in the management of diabetic peripheral neuropathic pain. Pain Med. Antidepressant treatment of fibromyalgia. A meta-analysis and review. Management of fibromyalgia syndrome. Registered Nurses' Association of Ontario. Assessment and Management of Pain: Supplement.

Featured Issue Featured Supplements. US Pharm. Neuropathic Pain Two common forms of chronic neuropathic pain are diabetic neuropathy and postherpetic neuralgia, which account for 3 million and 1 million people, respectively, in the United States.

Fibromyalgia Fibromyalgia is a musculoskeletal condition characterized by widespread pain and muscle tenderness that is often accompanied by fatigue, sleep disturbances, and depression. To comment on this article, contact rdavidson jobson. Related CE. View More CE. Related Content. Take Quiz. SSRIs discontinuation syndrome is characterized by sensory and gastrointestinal symptoms, dizziness, lethargy, and sleep disturbances [ 25 ]. Its use for chronic pain management has been highlighted in several clinical trials including modest numbers of patients Table 1.

For chronic tension-type headache, fluoxetine administered in 20 mg daily dose is equally efficient to desipramine [ 26 ]. For somatoform pain disorders, the analgesic effect is related to treatment duration and is related to its antidepressant effect as depressive patients show greater improvement compared to non-depressed ones [ 28 ].

Fluoxetine was found to be efficient for the treatment of fibromyalgia when compared to placebo or amitriptyline [ 29 , 30 ]. Non-depressed patients with severe chronic tension-type headache respond to fluvoxamine 50— mg daily [ 31 ], and it is efficient in central post-stroke pain, cancer pain, and osteoarthritis [ 32 , 33 , 34 ]. However, for chronic cancer pain, its beneficial effect has not yet been proven [ 35 ]. In small sample size studies, it has proven to be efficient in non-cardiac chronic chest pain and chronic pelvic pain of prostatic origin in men [ 36 , 37 ], but not in women with chronic pelvic pain [ 38 ].

For tension-type daily headache, two studies failed to prove any beneficial effect [ 39 , 40 ]. Foster et al. For chronic low back pain, doses of 20 mg are less efficient than maprotiline, and the effects are similar to placebo [ 42 , 43 ]. In fibromyalgia, paroxetine improves overall symptomatology, but the effect on pain is less robust [ 44 ].

Paroxetine has been shown to be useful for the treatment of diabetic peripheral neuropathy, but not more efficient than imipramine [ 45 ]. In a mixed study comparing paroxetine and citalopram versus gabapentin, the comparable efficiency of these two SSRIs with gabapentin was shown [ 46 ].

It has been investigated for the treatment of fibromyalgia and chronic tension-type headache, with no beneficial results [ 47 , 48 , 49 ], while for somatoform pain disorders it has only moderate analgesic effect [ 50 , 51 , 52 ]. For chronic low back pain, citalopram has similar results compared to duloxetine [ 53 ].

It has pain-relieving effects in painful diabetic neuropathy and somatoform disorders [ 54 , 55 ]. For the treatment of pain symptoms associated with depression, escitalopram is equally effective with nortriptyline [ 56 ].

This category includes drugs with very different chemical structure and includes venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipran. Side effects of SNRIs are common to all antidepressants, but these drugs add dry mouth and constipation due to increased levels of noradrenaline. The risk of withdrawal because of side effects, in patients with chronic pain, was highest for milnacipran and followed by venlafaxine and duloxetine [ 57 ].

It is indicated for major depressive disorder MDD and also for anxiety, panic disorders, and social phobia management. An experimental study showed its antihyperalgesic effect after a single administration in a diabetic neuropathic pain model, a result reversed by pretreatment with yohimbine and chloroamphetamine, but not by naloxone [ 58 ]. Long ago, a short case report raised attention to the potential beneficial effect of venlafaxine in chronic pain management [ 59 ], and later others confirmed its beneficial effects in managing neuropathic pain: peripheral neuropathy, postherpetic neuropathy, headache, and multiple sclerosis.

In a systematic review on neuropathic pain, the authors found four trials high quality evidence : two with positive results at doses of — mg venlafaxine ER daily and two with negative results lower doses. The number needed to treat NNT was 6. In elderly patients with low back pain and depression, mg venlafaxine showed efficacy, but the authors suggested that patients who did not respond to small doses may benefit from dose augmentation after a 2-week period [ 61 ].

Still, further trials are needed to determine optimal doses and efficiency in patients with SCI without MDD [ 62 , 63 ]. Studies in patients with taxane-oxaliplatin-induced neurotoxicity showed clinical improvement after venlafaxine Venlafaxine had good results in acute pain; in patients with cancer breast surgery, the preoperative administration of A former Cochrane meta-analysis reported little evidence to support the recommendation of venlafaxine in neuropathic pain management and noted that venlafaxine promoted fatigue, nausea, dizziness, and somnolence with a low incidence [ 67 ].

Eventually, two recent reviews 11 and 13 trials found that venlafaxine was beneficial in neuropathic pain management with good tolerability claiming the necessity for further research to expand these findings [ 68 , 69 ]. There are contradictory findings in these recent reviews, but there is need for further good quality evidence. The daily recommended dose is 50 mg. Desvenlafaxine is the salt of an active metabolite of venlafaxine, and the ER form allows 1 day administration.

Adverse effects are dose-dependent and typical to all antidepressants. Doses of — mg showed efficacy in DPN management, with effect sizes similar to duloxetine [ 70 ] and with increased side effects at higher doses. At the moment, there is a lack of evidence to support the use of desvenlafaxine in chronic pain management. Aside from MDD and urinary incontinence, duloxetine is indicated for anxiety disorder, chronic pain in diabetic neuropathy, fibromyalgia, musculoskeletal pain, and osteoarthritis.

It has a moderate bioavailability, with an elimination half-time of 12 h. It is metabolized in the liver and does not possess any active metabolite. Duloxetine exerts antihyperalgesic and allodynic effects, by impairing nociception at a peripheral level blocks NaV 1. With acute administration, DLX leads to elevated levels of NA and 5-HT, and with chronic treatment, it does not affect further basal levels of these monoamines [ 72 ]. Because of interfering with platelet function, it is indicated to stop its administration 4 days before surgery.

Data from animal pain models and clinical studies on DLX administration in perioperative setting spine, knee, breast surgery suggested its analgesic effects. Pre- and postoperative duloxetine reduced h opioid consumption, delayed first analgesic requirement, and reduced incidence of chronic postoperative pain at 6 months, being of primary interest for patients with preoperative chronic pain and spine surgery [ 75 , 76 , 77 ]; results from ongoing studies will respond to questions remained unanswered.

Duloxetine shows good tolerability with dizziness and nausea, dry mouth, and constipation, as more frequent side effects [ 78 ]. It did not link to alpha adrenoreceptors, muscarinic cholinergic, and histaminic receptors and showed no effect on beta-adrenergic receptors sensitivity, thus having reduced side effects. The drug has an excellent bioavailability with a mean peak plasma concentration reached between 0.

Studies on the efficacy of milnacipran in psychiatric patients revealed its significant superiority when compared to SSRIs. Most frequent adverse effects were nausea, dry mouth, and headaches [ 85 ].

Milnacipran has FDA approval for the management of fibromyalgia. In , Obata et al. In a Cochrane meta-analysis, Cording et al. Despite the evidence that milnacipran or mg was found to be useful in neuropathic pain, as compared with placebo, Derry et al. At usual doses, this drug is known to possess a higher potency for norepinephrine twofold reuptake inhibition, as compared with 5-HT [ 91 ]; but with higher doses, it showed equal efficacy in increasing 5-HT and NE levels [ 92 ].

We have not found any data regarding its use in chronic pain patients. Animal studies have suggested that these receptors are included in the descending pain inhibitory systems [ 94 , 95 ], and their activation is involved in reducing the acute nociceptive and neuropathic pain [ 96 ].

The main excretion route is renal, and the biological half-time is 7 h. Side effects are not only shared with the other antidepressants but also list dry mouth, orthostatic hypotension, cardiac arrhythmias, and priapism. Trazodone showed some efficacy in several chronic pain conditions represented in Table 6 , but future studies are needed. Doses of — mg are indicated for the treatment of MDD, panic disorders, and aggressive behavior. It acts as an antagonist of 5-HT A2 and 5-HT C2 receptors and serotonin, norepinephrine, and dopamine reuptake inhibitor.

Its effects on the mentioned receptors enhance neurotransmission by an increased binding on the 5-HT A1 receptors. Nefazodone has a biological half-time between 2 and 4 h and is excreted in urine. Frequent side effects are dry mouth, dizziness, and sleepiness, and rare, severe liver damage [ 98 ].

Even if it shows an excellent clinical profile, at this time we found only a two-center open-label study on the efficacy of nefazodone on preventing chronic daily headache. In some cases, where available, results of special blood tests may offer clues about how your body may respond to a particular antidepressant. However, other variables besides genetics can affect your response to medication. When choosing an antidepressant, your doctor takes into account your symptoms, any health problems, other medications you take and what has worked for you in the past.

Typically, it may take several weeks or longer before an antidepressant is fully effective and for initial side effects to ease up. Your doctor may recommend dose adjustments or different antidepressants, but with patience, you and your doctor can find a medication that works well for you. There is a problem with information submitted for this request. Sign up for free, and stay up-to-date on research advancements, health tips and current health topics, like COVID, plus expert advice on managing your health.

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Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Mayo Clinic does not endorse any of the third party products and services advertised. A single copy of these materials may be reprinted for noncommercial personal use only. This content does not have an English version. This content does not have an Arabic version. See more conditions. Serotonin and norepinephrine reuptake inhibitors SNRIs. Products and services. Serotonin and norepinephrine reuptake inhibitors SNRIs Antidepressant SNRIs help relieve depression symptoms, such as irritability and sadness, but some are also used for anxiety disorders and nerve pain.

By Mayo Clinic Staff. Thank you for Subscribing Our Housecall e-newsletter will keep you up-to-date on the latest health information. Please try again. Something went wrong on our side, please try again. Show references Depression: FDA-approved medications may help. Food and Drug Administration. Accessed Aug. Depression basics. National Institute of Mental Health. Revisions to product labeling.

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