Management of interstitial cystitis/bladder pain syndrome with tricyclic bladder pain syndrome with tricyclic

The tricyclic antidepressant amitriptyline (Elavil) has become a staple of oral treatment of IC/BPS (interstitial cystitis/bladder pain syndrome). The 2014 American Urologic Association (AUA) revised Guideline on IC/BPS listed amitriptyline as a second-line treatment of IC/BPS [1]. Other second-line treatments in the AUA Guideline included other oral medications (hydroxyzine, cimetidine, pentosan polysulfate), intravesical instillation (lidocaine, heparin, DMSO), manual physical therapy, and multimodal pain management. The use of amitriptyline to manage IC/BPS is an off-label use; however, clinical experience and data from trials supported its use. The AUA Guideline graded the strength of evidence as Grade B, meaning that there were randomized controlled trials (RCTs) but there were also weaknesses in these RCTs. The use of amitriptyline is designated an Option on the Guideline, which means that there is uncertainty in the balance between benefits and risks/burden of the treatment. Although amitriptyline may benefit a subset of IC/BPS patients who are able to tolerate the medication at higher doses (50-75 mg at bedtime), it is not possible to identify a priori who the responders might be. Adverse effects, while mostly mild to moderate, are reported by almost all patients and constitute the drawback of this therapeutic approach to manage IC/BPS. Here, we shall focus the discussion on amitriptyline, the most commonly used tricyclic antidepressant to manage IC/BPS. Other tricyclics (nortriptyline), selective serotonin uptake inhibitors (sertraline), and serotonin norepinephrine update inhibitors (duloxetine) will also be reviewed.