Fibromyalgia Pharmacologic Management

Aka: Fibromyalgia Pharmacologic Management

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

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)
  3. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
    1. Venlafaxine (Effexor)
      1. Sayer (2003) Ann Pharmacother 37:1561-5 [PubMed]
    2. Duloxetine (Cymbalta)
    3. Milnacipran (Savella)
  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. Dose of 450 mg/day reduced pain, Fatigue, Insomnia
    3. 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) up to 1000 mg PO qid
  2. NSAIDs
    1. Less effective than in other Rheumatologic Disease
  3. Cyclobenzaprine (Flexeril)
    1. Dose: 10 mg (up to 30 mg has been used) at bedtime
    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. 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. Goldenberg (2004) JAMA 292:2388-95 [PubMed]
  4. Kodner (2015) Am Fam Physician 91(7): 472-8 [PubMed]

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