Combination of morphine with nortriptyline for neuropathic pain.
First-line neuropathic pain drugs, including tricyclic antidepressants, are not always effective, and opioids have been recommended as second line. This trial evaluates a nortriptyline-morphine combination, compared with each monotherapy. In this randomized, double-blind crossover trial, patients with neuropathic pain were enrolled at 1 site between January 25, 2010, and May 22, 2014, and randomized in a 1:1:1 ratio using a balanced Latin square design to receive oral nortriptyline, morphine, and their combination. During each of three 6-week periods, doses were titrated toward maximal tolerated dose (MTD). The primary outcome was average daily pain at MTD, and secondary outcomes included other pain, mood and quality of life measures, and adverse effects. Sixty-two patients were screened, 52 enrolled, and 39 completed at least 2 treatment periods. Average daily pain (0-10) at baseline was 5.3 and at MTD was 2.6 for combination vs 3.1 for nortriptyline (P = 0.046) and 3.4 for morphine (P = 0.002). Brief Pain Inventory scores for average and present pain were also significantly lower for combination vs each monotherapy. Combination treatment resulted in moderate-severe constipation in 43% vs 46% with morphine (P = 0.82) and 5% with nortriptyline (P < 0.0001). Combination treatment resulted in moderate-severe dry mouth in 58% vs 49% with nortriptyline (P = 0.84) and 13% with morphine (P < 0.0001). This trial suggests superior efficacy of a nortriptyline-morphine combination over either monotherapy with constipation, dry mouth, and somnolence as the most frequent adverse effects.
Departments of Anesthesiology & Perioperative Medicine and Biomedical & Molecular Sciences, Public Health Sciences and Mathematics & Statistics, and Psychology, Queen's University, Kingston, ON, Canada Section of Neurology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada Department of Anesthesiology, Kingston General Hospital, Kingston, Ontario, Canada.
Ian
I
Gilron
Dongsheng
D
Tu
Ronald R
RR
Holden
Alan C
AC
Jackson
Deborah
D
DuMerton-Shore
D000328:Adult; D000339:Affect / Q000187:drug effects; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D003248:Constipation / Q000139:chemically induced; D004311:Double-Blind Method; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use*; D009437:Neuralgia / Q000188:drug therapy* / Q000503:physiopathology; D009661:Nortriptyline / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D059408:Pain Management / Q000379:methods; D010147:Pain Measurement / Q000379:methods; D011788:Quality of Life / Q000523:psychology; D016896:Treatment Outcome; D014987:Xerostomia / Q000139:chemically induced
D000701:Analgesics, Opioid; D000929:Antidepressive Agents, Tricyclic; D009020:Morphine; D009661:Nortriptyline