Acupuncture and Amitriptyline for HIV-Related Peripheral Neuropathic Pain

To the Editor: Dr Shlay and colleagues¹ appropriately note several potential problems that may have resulted in their finding that neither amitriptyline nor acupuncture appeared to be beneficial for the pain due to HIV-related peripheral neuropathy. I wish to present 2 other issues that may also have affected the outcome.

The first is that the maximum dose of amitriptyline used was only 75 mg/d. The authors cite 2 articles supporting this decision.^2- 3 However, neither of these articles appear to do so. In fact, in their study of diabetic neuropathy, Sindrup et al³ used a dosage range of imipramine from 125 to 350 mg/d and stated "it is important to not discontinue treatment because of an inadequate response on a standard dose of for example 100 mg imipramine per day."³(p514) As amitriptyline and imipramine are usually considered to be of roughly equal potency and because many other studies supporting the use of antidepressants for analgesia have used doses higher than 75 mg/d of amitriptyline or the equivalent,⁴ including at least 1 coauthored by 1 of the current authors, Dr Max,⁵ it is difficult to understand why the dose was limited. It is quite possible that the poor medication response resulted from a subtherapeutic dose.