Fibromyalgia Pharmacologic Management

Aka: Fibromyalgia Pharmacologic Management

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II. Precautions

  1. Non-medication is the mainstay of Fibromyalgia management
    1. See Fibromyalgia Non-Pharmacologic Management
  2. Medications have underwhelming benefit in Fibromyalgia
    1. Number Needed to Treat approaches 10
    2. Start medications at low dose and slowly advance
    3. When medications are found effective at target dose, Continue for at least 12 months

III. Management: Antidepressants

  1. Benefits
    1. Assists with local pain, stiffness and sleep
    2. Does not affect Tender Points
  2. Tricyclic Antidepressants
    1. More effective than Duloxetine and Milnacipran
    2. Amitriptyline (Elavil)
      1. First week: 10 mg orally at bedtime
      2. Next three weeks: 25 mg orally at bedtime
      3. Later: 50 mg orally at bedtime
    3. Nortriptyline (Pamelor)
      1. Same dosing as Amitriptyline
  3. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
    1. Venlafaxine (Effexor)
      1. Sayer (2003) Ann Pharmacother 37:1561-5 [PubMed]
    2. Duloxetine (Cymbalta)
      1. Start at 20 to 30 mg every morning and titrate to 60 mg every morning
    3. Milnacipran (Savella)
      1. Start at 12.5 mg orally every morning and titrate to 50 mg orally twice daily
  4. Selective Serotonin Reuptake Inhibitors (SSRI)
    1. Combination: Fluoxetine and Amitriptyline
      1. Efficacy: Combination better than either drug alone
      2. Start SSRI and Amitriptyline dosing low
      3. Goldenberg (1996) Arthritis Rheum 39:1852-9 [PubMed]
    2. Higher doses of Prozac required for effect
      1. Arnold (2002) Am J Med 112:191-7 [PubMed]
  5. References
    1. O'Malley (2000) J Gen Intern Med 15:659-66 [PubMed]

IV. Management: Anticonvulsants

  1. Gabapentin (Neurontin)
  2. Pregabalin (Lyrica)
    1. Anticonvulsant effective in Fibromyalgia
    2. Start at 25 to 50 mg at bedtime and titrate to 150 to 450 mg at bedtime
    3. Dose of 450 mg/day reduced pain, Fatigue, Insomnia
    4. Pain improvement was in reducing pain level rating from 7 to 4-5
  3. Reference
    1. Crofford (2004) Curr Rheumatol Rep 6:274-80 [PubMed]
    2. Crofford (2005) Arthritis Rheum 52: 1264-73 [PubMed]

V. Management: Analgesics and other agents

  1. Acetaminophen (Tylenol)
    1. Dosing up to 1000 mg orally four times daily
  2. NSAIDs
    1. Less effective than in other Rheumatologic Disease
  3. Cyclobenzaprine (Flexeril)
    1. Start at 5 to 10 mg at bedtime (may titrate to 10 mg three times daily)
    2. Assists with local pain, sleep and Tender Points
    3. Tofferi (2004) Arthritis Rheum 51:9-13 [PubMed]
  4. Quetiapine (Seroquel)
    1. May improve depressed mood, sleep and reduce overall pain in Fibromyalgia (low quality evidence)
    2. Walitt (2016) Cochrane Database Syst Rev (6):CD011804 +PMID:27251337 [PubMed]
  5. Opioids
    1. Most guidelines do NOT recommend Tramadol (Ultram) and other Opioids for Fibromyalgia
    2. Risk of Opioid Dependence and misuse and hyperalgesia
    3. Tramadol specifically risks Serotonin Syndrome when combined with SSRI, SNRI and Tricyclic Antidepressants
  6. Complementary and and Alternative Medicine (CAM) Treatments
    1. No consistent benefits identified
    2. Terry (2012) Clin Rheumatol 31(1): 55-66 [PubMed]

VI. References

  1. Money and Glauser (2017) Crit Dec Emerg Med 31(1): 15-21
  2. Chakrabarty (2007) Am Fam Physician 76:247-54 [PubMed]
  3. Di Franco (2010) Clin Exp Rheumatol 28(6 suppl 63): S110-6 [PubMed]
  4. Goldenberg (2004) JAMA 292:2388-95 [PubMed]
  5. Kodner (2015) Am Fam Physician 91(7): 472-8 [PubMed]
  6. Thorpe (2018) Cochrane Database Syst Rev (2): CD010585 [PubMed]
  7. Winslow (2023) Am Fam Physician 107(2): 137-44 [PubMed]

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