OBJECTIVE:To assess the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in the management of chronic pain. METHODS:Randomized, controlled trials of SSRIs in the management of chronic pain were identified by searching MEDLINE from 1966 to 1997 and by contacting the manufacturers of SSRIs available in the United States. MAIN RESULTS:Nineteen studies were identified, including 10 on the treatment of headache, 3 on diabetic neuropathy, 3 on fibromyalgia, and 3 on mixed-chronic pain. SSRIs were consistently helpful for mixed-chronic pain. Results were conflicting for migraine headache, tension headache, diabetic neuropathy, and fibromyalgia. T he clinical management of chronic pain remains a challenge. Despite advances in pain research and clinical treatment, rates of disability due to chronic pain continue to climb worldwide. 1 Although chronic pain is treated with many medications, such as tricyclic antidepressants, nonsteroidal anti-inflammatory drugs, anticonvulsants, and opioids, none has shown outstanding efficacy. Narcotics are usually avoided because of the risk of developing tolerance, dependence, and functional deterioration. 2 Tricyclic antidepressants have proven efficacy in the treatment of chronic pain conditions such as diabetic neuropathy, fibromyalgia, chronic headaches, and post-herpetic neuralgia. 3 Their ability to relieve pain in these conditions appears to be independent of their antidepressant effect and may be related to their effect on neuronal reuptake of serotonin and norepinephrine. Unfortunately, side effects including dry mouth, constipation, orthostatic hypotension, and urinary retention often limit their use. CONCLUSIONS:Fluoxetine was introduced as the first selective serotonin reuptake inhibitor (SSRI) in the United States in 1988. Since then, SSRIs have become the most frequently prescribed antidepressant medications owing to their favorable side-effect profile. 4 More than half of antidepressant prescriptions written in the primary care setting are for conditions other than depression. 5 There is considerable interest in the use of SSRIs for the management of chronic pain, although they are not currently approved by the Food and Drug Administration for this purpose. This review summarizes available data on the value of these medications for pain control in several clinical situations. METHODSWe used the National Library of Medicine search engine to search MEDLINE from 1966 to 1997 using the medical subject heading (MeSH) term "pain," exploding it, and adding the following words in all fields: pain, neuropathy, migraine, and fibromyalgia. We also searched using the MeSH term "serotonin uptake inhibitors" and the following words in all fields: sertraline, paroxetine, fluoxetine, fluvoxamine, femoxetine, zimelidine, and citalopram. We combined results of these two searches with the term "and," and selected for review randomized double-blind, controlled studies published in English and performed on humans. References from studies reviewed provided additional sources of...

OBJECTIVE: To assess the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in the management of chronic pain. METHODS:Randomized, controlled trials of SSRIs in the management of chronic pain were identified by searching MEDLINE from 1966 to 1997 and by contacting the manufacturers of SSRIs available in the United States.MAIN RESULTS: Nineteen studies were identified, including 10 on the treatment of headache, 3 on diabetic neuropathy, 3 on fibromyalgia, and 3 on mixed-chronic pain. SSRIs were consistently helpful for mixed-chronic pain. Results were conflicting for migraine headache, tension headache, diabetic neuropathy, and fibromyalgia.CONCLUSIONS: SSRIs appear to be beneficial for mixedchronic pain. It is unclear, from the available evidence, whether SSRIs are beneficial for migraine headaches, tension headaches, diabetic neuropathy, or fibromyalgia. For those patients it may be reasonable to reserve SSRIs for those who fail to respond to other medications or who are intolerant of their side effects. KEY WORDS: chronic pain, management of; selective serotonin reuptake inhibitors. J GEN INTERN MED 1997;12:384-389.T he clinical management of chronic pain remains a challenge. Despite advances in pain research and clinical treatment, rates of disability due to chronic pain continue to climb worldwide. 1 Although chronic pain is treated with many medications, such as tricyclic antidepressants, nonsteroidal anti-inflammatory drugs, anticonvulsants, and opioids, none has shown outstanding efficacy. Narcotics are usually avoided because of the risk of developing tolerance, dependence, and functional deterioration. 2 Tricyclic antidepressants have proven efficacy in the treatment of chronic pain conditions such as diabetic neuropathy, fibromyalgia, chronic headaches, and post-herpetic neuralgia. 3 Their ability to relieve pain in these conditions appears to be independent of their antidepressant effect and may be related to their effect on neuronal reuptake of serotonin and norepinephrine. Unfortunately, side effects including dry mouth, constipation, orthostatic hypotension, and urinary retention often limit their use.Fluoxetine was introduced as the first selective serotonin reuptake inhibitor (SSRI) in the United States in 1988. Since then, SSRIs have become the most frequently prescribed antidepressant medications owing to their favorable side-effect profile. 4 More than half of antidepressant prescriptions written in the primary care setting are for conditions other than depression. 5 There is considerable interest in the use of SSRIs for the management of chronic pain, although they are not currently approved by the Food and Drug Administration for this purpose. This review summarizes available data on the value of these medications for pain control in several clinical situations. METHODSWe used the National Library of Medicine search engine to search MEDLINE from 1966 to 1997 using the medical subject heading (MeSH) term "pain," exploding it, and adding the following words in all fields: pain, ne...

OBJECTIVE: To summarize current information on the relation between CD4 counts and the risk of different HIV-related diseases. MEASUREMENTS AND MAIN RESULTS: MEDLINE search ofEnglish language articles between 1985 and 1996 using the medical subject heading (MeSH) term "CD4 lymphocyte count" and searches using key words of multiple HIV-related diseases were conducted. Some HIV-related diseases can be stratified to different CD4 count levels. Regardless of their CD4 count, HIV-infected patients are susceptible to sinusitis, Kaposi's sarcoma, community-acquired pneumonia, and oral hairy leukoplakia. In advanced HIV, when CD4 is below 200/ mm 3 , Pneumocystis carinii pneumonia, toxoplasmosis, progressive multifocal leukoencephalopathy, Mycobacterium avium complex, molluscum contagiosum, and bacillary angiomatosis all increase in incidence. In very advanced HIV disease, when CD4 counts are below 50/mm 3 , patients are at risk of pseudomonas pneumonia, cytomegalovirus retinitis, central nervous system lymphoma, aspergillosis, and disseminated histoplasmosis.KEY WORDS: CD4 count; HIV-related disease; risk stratification. J GEN INTERN MED 1998;13:131-136.

Trimethoprim-sulfamethoxazole is an important medication for the treatment and prevention of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. Use of this medication has been limited by the high frequency of adverse reactions that occur in patients with human immunodeficiency virus disease. This article reviews the incidence and spectrum of adverse reactions and options for continuing therapy with trimethoprim-sulfamethoxazole in human immunodeficiency virus-infected patients who have adverse reactions.