Treatment of Chronic Low Back Pain with Amitriptyline

Efficacy of Amitriptyline

• The American College of Physicians suggests that tricyclic antidepressants like amitriptyline show moderate efficacy for chronic low back pain relief, although evidence is limited 3, 4
• Moderate-quality evidence shows no significant difference between tricyclic antidepressants and placebo for pain, and low-quality evidence shows no differences for function 2, 5

Place in Therapeutic Algorithm

• The American College of Physicians recommends nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment, with moderate efficacy for pain relief 2, 5
• Amitriptyline at low dose (25-50 mg/day) may be considered as second-line treatment, with moderate efficacy for pain relief and functional improvement 1
• Duloxetine is associated with small improvements in pain intensity and function compared to placebo 2, 5

Special Populations

• Amitriptyline may be particularly useful in patients with neuropathic component to their pain, sleep disturbances, or concomitant depression 1

Approach to Treatment

• The American College of Physicians recommends combining amitriptyline with non-pharmacological approaches (physical exercise, cognitive-behavioral therapy) 1
• For low back pain with radiculopathy, consider adding gabapentine, which is more effective for the neuropathic component 1, 6