II. Precautions
- Non-medication is the mainstay of Fibromyalgia management
- Medications have underwhelming benefit in Fibromyalgia
- Number Needed to Treat approaches 10
- Start medications at low dose and slowly advance
- When medications are found effective at target dose, Continue for at least 12 months
III. Management: Antidepressants
- Benefits
- Assists with local pain, stiffness and sleep
- Does not affect Tender Points
-
Tricyclic Antidepressants
- More effective than Duloxetine and Milnacipran
- Amitriptyline (Elavil)
- First week: 10 mg orally at bedtime
- Next three weeks: 25 mg orally at bedtime
- Later: 50 mg orally at bedtime
- Nortriptyline (Pamelor)
- Same dosing as Amitriptyline
-
Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
- Start at 20 to 30 mg every morning and titrate to 60 mg every morning
- Milnacipran (Savella)
- Start at 12.5 mg orally every morning and titrate to 50 mg orally twice daily
-
Selective Serotonin Reuptake Inhibitors (SSRI)
- Combination: Fluoxetine and Amitriptyline
- Efficacy: Combination better than either drug alone
- Start SSRI and Amitriptyline dosing low
- Goldenberg (1996) Arthritis Rheum 39:1852-9 [PubMed]
- Higher doses of Prozac required for effect
- Combination: Fluoxetine and Amitriptyline
- References
IV. Management: Anticonvulsants
- Gabapentin (Neurontin)
-
Pregabalin (Lyrica)
- Anticonvulsant effective in Fibromyalgia
- Start at 25 to 50 mg at bedtime and titrate to 150 to 450 mg at bedtime
- Dose of 450 mg/day reduced pain, Fatigue, Insomnia
- Pain improvement was in reducing pain level rating from 7 to 4-5
- Reference
V. Management: Analgesics and other agents
-
Acetaminophen (Tylenol)
- Dosing up to 1000 mg orally four times daily
-
NSAIDs
- Less effective than in other Rheumatologic Disease
-
Cyclobenzaprine (Flexeril)
- Start at 5 to 10 mg at bedtime (may titrate to 10 mg three times daily)
- Assists with local pain, sleep and Tender Points
- Tofferi (2004) Arthritis Rheum 51:9-13 [PubMed]
-
Quetiapine (Seroquel)
- May improve depressed mood, sleep and reduce overall pain in Fibromyalgia (low quality evidence)
- Walitt (2016) Cochrane Database Syst Rev (6):CD011804 +PMID:27251337 [PubMed]
-
Opioids
- Most guidelines do NOT recommend Tramadol (Ultram) and other Opioids for Fibromyalgia
- Risk of Opioid Dependence and misuse and hyperalgesia
- Tramadol specifically risks Serotonin Syndrome when combined with SSRI, SNRI and Tricyclic Antidepressants
- Complementary and and Alternative Medicine (CAM) Treatments
- No consistent benefits identified
- Terry (2012) Clin Rheumatol 31(1): 55-66 [PubMed]
VI. References
- Money and Glauser (2017) Crit Dec Emerg Med 31(1): 15-21
- Chakrabarty (2007) Am Fam Physician 76:247-54 [PubMed]
- Di Franco (2010) Clin Exp Rheumatol 28(6 suppl 63): S110-6 [PubMed]
- Goldenberg (2004) JAMA 292:2388-95 [PubMed]
- Kodner (2015) Am Fam Physician 91(7): 472-8 [PubMed]
- Thorpe (2018) Cochrane Database Syst Rev (2): CD010585 [PubMed]
- Winslow (2023) Am Fam Physician 107(2): 137-44 [PubMed]