以抗抑郁药治疗纤维肌痛综合征：meta分析。

背景：纤维肌痛综合征（FMS）是一种慢性疼痛障碍，与多种衰弱症状和高额疾病相关费用有关。选择有效的治疗方案是必要的。目的：通过对一项随机对照临床试验进行Meta分析，确定抗抑郁药在治疗FMS中疗效。数据来源：通过2008年8月对MEDLINE、PsycINFO、Scopus和Cochrane图书馆数据库进行的全面检索获得数据。对原始研究的参考资料、荟萃分析以及在FMS中应用抗抑郁药的综述进行回顾。研究选择：分析以三环和四环抗抑郁剂（TCAs）、选择性5-羟色胺重吸收抑制剂（SSRIs）、羟色胺和去甲肾上腺素重吸收抑制剂（SNRIs）以及单胺氧化酶抑制剂（MAOIs）所进行的随机安慰剂对照试验。数据抽取与数据综合：两位作者独立抽取数据。通过一项随机效应模型使用标准平均差（SMDs）对效果进行总结。结果：涉及1427例参加者的18项随机对照试验（持续时间中位数，8周;全距，4－28周）被纳入研究。总体而言，有充分证据显示，抗抑郁药与疼痛（表面贴装，-0.43;95％置信区间[CI]，-0.55－-0.30）、疲劳（SMD，-0.13;95％CI，-0.26－-0.01）、抑郁情绪（SMD，-0.26;95％CI，-0.39－-0.12）以及睡眠障碍（SMD，-0.32;95％CI，-0.46－-0.18）的减轻之间存在着联系。有充分证据显示，抗抑郁药物和与健康相关的生活质量改善之间存在着联系（SMD，-0.31;95％CI，-0.42－-0.20）。疼痛减少效果的大小为：TCAs（SMD，-1.64;95％CI，-2.57－-0.71）的效果较大、MAOIs（SMD，-0.54;95％CI，-1.02－-0.07）的效果中等，而SSRIs（SMD,-0.39;95%CI,-0.77－-0.01）和SNRIs（SMD,-0.36;95%CI,-0.46－-0.25）的效果较小。结论：在FMS患者中，抗抑郁药物治疗与疼痛、抑郁、疲劳、睡眠障碍以及与健康相关生活质量的改善之间存在着联系。

专家评价：MarcoRigatelliwithSilviaFerrariUniversityofModenaandReggioEmilia,ItalyPsychiatryAmitriptilineandduloxetinearetheantidepressants（ADs）withbestevidenceofefficacyinthecontrolofsomesymptomsoffibromyalgia.Thisarticleissignificantbecauseitisamethodologicallyaccuratemeta-analysisofavailableevidenceonthesubject,whichshouldhelpcounteractthewide-spreadtendencyofclinicianstohave"theirownreceipe".ADsarecommonlyusedforthetreatmentoffibromyalgia,notonlyinclinicallydepressedpatientsandthereforeprescribednotonlybypsychiatristsbutalsobyrheumatologists,internistsandotherphysicians.ThechoiceoftheappropriateAD（andrelatedclinicalvariables,i.e.whichdose,forhowlong,whichassociations）iscomplicatedandnotalwaysbasedonsoundevidence.Manageableandreliableinstrumentstoguideeverydayclinicalactivityarestronglyneeded.Moreover,researchinthisfieldcanimproveonlyifawideandaccurateanalysisofwhatisalreadyknownisperformedeverynowandthen.EighteenRCTsonantidepressanttreatmentoffibromyalgiawereincludedinthismeta-analysis,andthreemainobjectiveswerecompared:1）theeffectsofallADsondifferentsymptomsoffibromyalgia;2）thedifferencesbetweenADs;3）thevalidityofavailablescientificdata.Theresultswereasfollows:1）ADsareeffectiveonpain,insomnia,depressedmoodandqualityoflife,buteffectsizeissmall;ADshavenoeffectonfatigue;2）amongADs,themosteffectiveareamitriptilineandduloxetine.Amitriptilineisveryeffectiveinreducingpain,fatigue,insomnia;itisnoteffectiveondepressedmood,butonlybecauseitiscommonlyusedatlowerdosesthanthoserequiredforantidepressiveactivity;ithasasmalleffectonqualityoflife.Duloxetineiseffective,butlesssothanamitriptiline（smallereffectsize）,onpainandinsomnia;itiseffectiveondepressedmoodandonqualityoflife;3）onelimitationofpreviousresearchthatthemeta-analysisemphasizesisthelackofstudiesonlong-termefficacyofADs（themediandurationoftheRCTsincludedwas8weeksandnoclinicaldataafterdiscontinuationwereavailable）.Themeta-analysisprovidespracticalindicationsonthecorrectchoiceofADsinclinicalpracticeand,atthesametime,suggestionsforfurtherresearchinthefield.Furtherresearchshouldmainlyfocuson:long-termeffects;cost-effectivenessstudies;effectsofADtreatmentonindirectclinicalindicators,i.e.excessiveuseofspecialistreferral;whichADisbetterforwhichpatientandotherpatient-specificfeaturestobeassessedbeforechoosingtherighttherapy.