Combining nortriptyline with morphine may provide superior analgesia over monotherapies

The Pharmaceutical Journal23 APR 2015

Neuropathic pain (NP) is notoriously difficult to treat. Average daily pain scores were reduced significantly more with combination therapy than with either nortriptyline or morphine alone.

Multiple mechanisms are involved in the pathophysiology of neuropathic pain (image shows cortical areas involved with pain processing)

Neuropathic pain (NP) is difficult to treat. Multiple mechanisms are involved in the pathophysiology of NP and there is a rationale for combining analgesics with different modes of action.

Building on earlier reports supporting combination therapy, US researchers evaluated the combination of morphine, a narcotic pain reliever, and nortriptyline, a tricyclic antidepressant, in 39 patients with NP.

Results of this randomised, double-blind, crossover study, published in Pain^[1], found that average daily pain scores were reduced significantly more with combination therapy than with either nortriptyline or morphine alone. Scores on the Brief Pain Inventory (average and present pain) were also significantly lower for combination versus monotherapy. The most frequent adverse events were constipation, dry mouth and somnolence.

References:

^[1]Gilron I, Tu D, Holden RR et al. Combination of morphine with nortriptyline for neuropathic pain. Pain 2015. doi:10.1097/j.pain.0000000000000149.

Citation: The Pharmaceutical Journal, 25 April 2015, Vol 294, No 7859, online | DOI: 10.1211/PJ.2015.20068367

Readers' comments (1)

Graham Parsons25 APR 2015 7:12
Not surprising as multi-modal approach BUT NICE do not recommend opioids for neuropathic pain and neither do they recommend nortriptyline as limited evidence for this drug (although probably class effect).
Nortriptyline also +++ expensive while amitryptyline more cost-effective.
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