Correspondence

Prevention and Treatment of the Complications of Diabetes Mellitus

N Engl J Med 1995; 333:802September 21, 1995

Article

To the Editor:

In their excellent review of the complications of diabetes mellitus (May 4 issue),1 Drs. Clark and Lee recommend amitriptyline as the tricyclic drug of choice for the treatment of symptomatic peripheral neuropathy, stating that this agent was “clearly more effective in relieving pain than desipramine” in a study by Max et al.2 Contrary to this statement, Max et al. did not find a statistically significant difference between desipramine and amitriptyline in relieving pain due to diabetic neuropathy, although amitriptyline tended to provide slightly greater relief than desipramine, on the basis of pain-diary scores. This distinction is important, because amitriptyline may have more adverse effects than desipramine in older patients. Older diabetic patients frequently have coexisting conditions, such as orthostatic hypotension, urinary retention, constipation, cognitive impairment, or a history of falls. As compared with desipramine, amitriptyline has more pronounced anticholinergic, sedative, and orthostatic effects, which may exacerbate these conditions. There is also good evidence linking amitriptyline and other highly anticholinergic tricyclic antidepressant drugs with an increased risk of hip fracture.3,4 Although there are few data, the risk of falls associated with desipramine may be lower because of its milder side effects. Amitriptyline should therefore be avoided in elderly patients when other treatment options are available.5

Jane E. Mahoney, M.D.
University of Wisconsin School of Medicine

Shelly L. Gray, Pharm.D.
University of Wisconsin School of Pharmacy, Madison, WI 53706

Molly Carnes, M.D.
William S. Middleton Veterans Affairs Medical Center, Madison, WI 53705

5 References

1
Clark CM Jr, Lee DA. Prevention and treatment of the complications of diabetes mellitus. N Engl J Med 1995;332:1210-1217
Full Text | Web of Science | Medline

2
Max MB, Lynch SA, Muir J, Shoaf SE, Smoller B, Dubner R. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992;326:1250-1256
Full Text | Web of Science | Medline

3
Ray WA, Griffin MR, Malcolm E. Cyclic antidepressants and the risk of hip fracture. Arch Intern Med 1991;151:754-756
CrossRef | Web of Science | Medline

4
Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ III. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987;316:363-369
Full Text | Web of Science | Medline

5
Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994;272:292-296
CrossRef | Web of Science | Medline

To the Editor:

Clark and Lee state, “Narcotic agents should be avoided because of their high potential for abuse.” They fail to note that amitriptyline, which they recommend, often does not adequately relieve pain in patients with diabetic neuropathy. More important, the authors do not mention that addiction is very rare in opioid-treated patients with pain resulting from malignant or nonmalignant disease. In a recent survey of 100 patients with neuropathic or nociceptive pain of nonmalignant origin who received opioids for prolonged periods, addiction or abuse did not occur, and good or moderate relief of pain was achieved in two thirds of the patients.1 Other investigators have reported similar results.2,3

Opioid therapy in patients with pain that is not relieved by other methods should not be avoided because of theoretical assumptions, which, together with government restrictions, lead to the undertreatment of patients with pain throughout the world.

Martin Klein, M.D.
Hermann Hesse Weg 2, 97276 Margetshöchheim, Germany

3 References

1
Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage 1992;7:69-77
CrossRef | Web of Science | Medline

2
Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986;25:171-186
CrossRef | Web of Science | Medline

3
France RD, Urban BJ, Keefe FJ. Long-term use of narcotic analgesics in chronic pain. Soc Sci Med 1984;19:1379-1382
CrossRef | Web of Science | Medline

Citing Articles (1)