First Line Drugs
- FLUOXETINE (N06AB03)
Second Line Drugs
- AMITRIPTYLINE (N06AA09)
Selective serotonin reuptake inhibitors (SSRIs) are not as helpful as tricyclics but may have a role when used with amitriptyline in depressed patients with fibromyalgia.They are better tolerated than tricyclics. Fluoxetine in the morning with evening amitriptyline was more effective than either agent alone in a double-blind controlled trial in fibromyalgia sufferers
Addendum Nov 14, 2013
The SNRI duloxetine provides a small but significant reduction in fibromyalgia pain but does not improve fatigue, quality of life or sleep disturbances. Duloxetine may be considered as first-line drug therapy in fibromyalgia patients with concomitant depression. Venlafaxine has not been studied in patients with fibromyalgia. (eTherapeutics)
amitriptyline 10 mg, hs; gradually increase to 25-50 mg, hs depending on response and side effects $0.01-0.02/day
or doxepin 10 mg, hs; gradually increase to 25-50 mg, hs depending on response and side effects $0.12-0.22/day
or alprazolam 0.5 mg, hs; increase to maximum of 3 mg, hs $0.09-0.56/day
or cyclobenzaprine 10 mg, hs $0.38/day
-Treatment for fibromyalgia may promote medicalization and prolong illness.
-Response to medication is generally not impressive; only 30-40% of patients report a significant benefit.
-The benefits of drug treatment have not been demonstrated in all trials.
-The etiology and pathophysiology of this disorder may not involve the musculoskeletal system.
-NSAIDs alone have not been shown to be effective.
-Studies on the usefulness of SSRIs have been contradictory.
-Cyclobenzaprine should not be used for more than 2 weeks.
Addendum (August 20, 2010)
Duloxetine (DLX), milnacipran (MLN), and pregabalin (PGB) are the only drugs licensed by the US Food and Drug Administration (FDA) for fibromyalgia syndrome (FMS). Evidence on the comparative benefits and harms is still accruing. The authors searched MEDLINE, SCOPUS, Cochrane Central Register of Controlled Trials, and sought unpublished data from the databases of FDA, US National Institutes for Health, and Industry through May 2009 for randomized controlled trials. Outcomes of interest were symptom reduction (pain, fatigue, sleep disturbance, depressed mood, reduced health-related quality of life), and adverse events. 17 studies with 7,739 patients met the inclusion criteria. The 3 drugs were superior to placebo except DLX for fatigue, MLN for sleep disturbance, and PGB for depressed mood. Adjusted indirect comparisons indicated no significant differences for 30% pain relief and dropout rates due to adverse events between the 3 drugs. Significant differences in average symptom reduction were found: DLX and PGB were superior to MLN in reduction of pain and sleep disturbances. DLX was superior to MLN and PGB in reducing depressed mood. MLN and PGB were superior to DLX in reducing fatigue. The risk of headache and nausea with DLX and MLN was higher compared with PGB. The risk of diarrhea was higher with DLX compared to MLN and PGB. There is evidence for the short-term (up to 6 months) efficacy of DLX, MLN, and PGB. Differences with regard to the occurrence of the key symptoms of FMS and to drug-specific adverse events may be relevant for the choice of medication. PERSPECTIVE: This article presents comparative data on the efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome. The results can help clinicians in choosing medication since the 3 drugs have different effects on the key symptoms of fibromyalgia syndrome and differences in side effects, contraindications, and warnings.
(Addendum Sept 5, 2013)
Amitriptyline probably does not work in neuropathic pain associated with HIV or treatments for cancer. Amitriptyline probably does work in other types of neuropathic pain (painful diabetic neuropathy, post-herpetic neuralgia, and post-stroke pain, and in fibromyalgia), though we cannot be certain of this. A best estimate is that amitriptyline provides pain relief in about 1 in 4 (25%) more people than does placebo (NNT* = 4.6 [95% confidence interval 3.6Ð6.6]), and about 1 in 4 (25%) more people than placebo report having at least 1 adverse event, probably not serious but disconcerting.*NNT = number needed to treat to benefit 1 individual.
Moore RA et al. Amitriptyline for neuropathic pain and fibromyalgia in adults. Cochrane Reviews, 2012, Issue 12. Art. No.: CD008242.DOI: 10.1002/14651858. CD008242.pub2.
This review contains 21 studies involving 1437 participants.
Tai Chi is helpful:
Of the 66 randomly assigned patients, the 33 in the tai chi group had clinically important improvements in the FIQ total score and quality of life. Mean (+/-SD) baseline and 12-week FIQ scores for the tai chi group were 62.9+/-15.5 and 35.1+/-18.8, respectively, versus 68.0+/-11 and 58.6+/-17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, -18.4 points; P<0.001). The corresponding SF-36 physical-component scores were 28.5+/-8.4 and 37.0+/-10.5 for the tai chi group versus 28.0+/-7.8 and 29.4+/-7.4 for the control group (between-group difference, 7.1 points; P=0.001), and the mental-component scores were 42.6+/-12.2 and 50.3+/-10.2 for the tai chi group versus 37.8+/-10.5 and 39.4+/-11.9 for the control group (between-group difference, 6.1 points; P=0.03). Improvements were maintained at 24 weeks (between-group difference in the FIQ score, -18.3 points; P<0.001). No adverse events were observed.
- Musculoskeletal System