Abstract
It is well know that refractory chronic pain is strongly associated with anxiety and depression symptoms in cancer patients [1]. This syndrome has a noxious paindepression feedback cycle that impacts on the patient's quality of life [1]. We report a patient with prostatic cancer and bone metastases with a severe pain syndrome who responded well to tianeptine, an antidepressant with serotoninergic activity.
Mr, R., is a 68-years-old male Caucasian. At the age of 66 an advanced prostatic adenocarcinoma was diagnosed, and radiotherapy was initiated. Bone metastases were concomitantly found. The improvement of the prostatic cancer was small and the metastases were multiple. A mild bone pain was treated with paracetamol. After a year the pain worsened and tenoxicam 20 mg/day was added, but the pain became more severe. We initially treated the pain with 400 mg/day of tramadol with partial response. A decision to commence morphine was discussed. The patient had no history of mental disorder and his family had no history of mood or anxiety disorder. He was examined by a psychiatrist who diagnosed a major depressive episode (DSM-IV-TR) associated with chronic pain syndrome (Clinical Global Impression –CGI –severity = 5). He was prescribed amitriptyline starting with 25 mg/day and increasing to 75 mg/day, at which dose he experienced severe anticholinergic sideeffects and mild confusion. Then amitriptyline was thus halted, and he was prescribed tianeptine 12.5 mg three times a day. After a 2 week period he described a remarkable improvement of pain control (7–1 on a analogue visual scale of pain), mood, anxiety and depressive symptoms were also improved (CGI severity = 2; CGI improvement = 1). At 6 months follow-up he had very mild pain complaints and no significant mood or anxiety symptoms. His quality of life had improved greatly and he has also returned to many of his daily activities. Tianeptine was chosen as it is well tolerated and has few drug–drug interactions [2], and has been reported to have analgesic properties [3]. It is a modified tricyclic that stimulates the uptake of serotonin, producing stress reduction (stimulation of the hypothalamo-pituitaryadrenal axis) and an anxiolytic effect [4].
Tianeptine may have a prominent thermal antinociceptive activity in chronic pain syndromes associated with tumours due to its increase in serotoninergic activity. Although tianeptine is a promising drug to treat the pain-depression feedback cycle, placebo-controlled trials are indicated to confirm this finding.