Medication

Fibromyalgia Medication by FaMily Editor
(Approved and verified by Dr Alex Allinson)


There is no cure for fibromyalgia, but medication aims to ease your symptoms as much as possible and to improve your quality of life.
The symptoms of fibromyalgia tend to vary widely from person to person, so you may be treated for your condition by several different healthcare professionals. For example, you may be treated by your GP, a rheumatologist (a specialist in conditions that affect the muscles and joints), or a neurologist (a specialist in conditions of the central nervous system).
Fibromyalgia can be treated in several different ways, and it is likely that you will need more than one kind of medication to ease your condition. However, all types of medication may not be effective for everyone with fibromylagia.
Typically the approach by doctors is to try and address a paticular symptom of fibromyalgia as there as yet no magic tablet that can deal with all the symptoms.

So you may be given one OR a combination of:

Painkillers to help with pain

Anti depressants to help with depression and sleep

Muscle relaxants and sleep medicines to help you sleep

Novel medications to help with pain and sleep (developed as anti-epileptics)


Painkillers

Simple analgesics such as paracetamol and other weak opioids can also be considered in the treatment of fibromyalgia. (Corticosteroids and strong opioids are not recommended.)
These drugs are designed to take the edge off less severe pain or to combat flare ups.

If paracetamol is not effective in easing your pain, your GP, or healthcare professional, may prescribe a stronger painkiller, such as codeine. You may also be prescribed a painkiller called tramadol, or one called nefopam. Both of these painkillers have been found to be effective in treating pain that is caused by fibromyalgia and act like synthetic codeine.

In some cases, in addition to your main painkiller, you may also be prescribed a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen. However, you should avoid taking NSAIDs if you have asthma, high blood pressure, or kidney, or heart, problems. They are also unsuitable for you if you have, or have had, a stomach problem, such as a peptic ulcer.

As well as easing pain, NSAIDs help to reduce inflammation. However, as fibromyalgia does not cause inflammation, they are not effective in treating the condition when taken on their own.

Dopamine Agonists

These drugs were originally developed as treatments for Parkinsons disease and Restless leg syndrome but can also be helpful for patients with fibromyalgia.

Dr Andrew Holman (Pacific Rheumatology Associates, Renton WA) said in 2004 that this is "the most promising treatment option I've seen in 12 years for fibromyalgia."

"The rationale behind using a dopamine agonist in fibromyalgia is not well worked out, but the leading theory—at least in my mind—is that these drugs act to decrease the autonomic arousal that fragments deep sleep," Holman explains. Dopamine in the brain affects a variety of functions, including pain, and the D3 dopamine receptors are found in the mesolimbic area, which is the part of the brain that inhibits arousal coming from the brain stem. The theory is that the D3 agonist at higher doses increases postsynaptic neurotransmission, possibly in the hippocampus, and this increases inhibition of the arousal, but he points out that the theory is still controversial - "it's highly speculative but intriguing."

5 - HT3 Receptor Agonists

Tropisetron is a serotonin 5-HT3 receptor antagonist used in the USA mainly as an antiemetic to treat nausea and vomiting following chemotherapy, although it has been used experimentally as an analgesic in cases of fibromyalgia.(1)

Antidepressants

Antidepressant medicines for fibromyalgia are not prescribed specifically to treat depression. These medications which treat centally mediated pain have become popular in recent years to treat FM as more research points to the brain and central nervous system, and not the periphery of the body, as the source of dysfunction in FM.They are commonly prescibed in lower doseages for fibromyalgia than for depression.

They are used to boost the levels of certain neurotransmitters, such as serotonin, noradrenaline (also known as norepinephrine), and dopamine. Neurotransmitters are chemicals that carry messages to and from the brain

It is thought that low levels of these neurotransmitters may be a factor in causing fibromyalgia, and that raising their levels may help to treat the condition and ease the pain of your symptoms. If you have fibromyalgia, there are many different types of antidepressant medicines that you may be prescribed. The choice of medicine will depend on the type of fibromyalgia that you have, and the severity of your symptoms, plus any side effects that the medicines may cause.

Antidepressants used to treat fibromyalgia include:

  • Tricyclic antidepressants - such as amitriptyline, nortriptyline, and dosulepin. These are usually the first choice of antidepressant and raise levels of serotonin and noradrenaline (norepinephrine) in order to ease pain and help you sleep.
  • Serotonin-norephinephrine reuptake inhibitors (SNRIs) - such as venlafaxine (Efexor) and duloxetine (Cymbalta) which raise levels of serotonin and noradrenaline (norepinephrine). Venlafaxine also raises levels of dopamine, as well as serotonin and noradrenaline.
  • Selective serotonin reuptake inhibitors (SSRIs) - such as citalopram (Cipramil), fluoxetine (Prozac), and paroxetine (Seroxat) which can be used to raise serotonin levels.

The most frequently studied pharmacologic therapy for fibromyalgia comprises low doses of tricyclic compounds. Most tricyclic antidepressants increase the concentrations of serotonin or norepinephrine, or both, by directly blocking their respective reuptake. Despite tolerability problems, the use of tricyclic antidepressants (particularly amitriptyline ) to treat the symptoms of pain, poor sleep and fatigue associated with fibromyalgia is supported by several randomized controlled trials (RCTs)(2).
The tolerability of tricyclic antidepressants can be improved by beginning with a low dose (e.g. 5–10 mg), giving the dose a few hours before bedtime, and slowly escalating the dose.

There has been a wealth of research on the use of anti-depressants as part of FM treatment, and the SNRIs seem especially helpful. It is thought that they influence central pain processing, thus decreasing pain and fatigue. They are not addictive, but common side effects include nausea, tiredness, headaches and rashes. The SSRIs fluoxetine, citalopram and paroxetine have each been evaluated in randomized, placebo-controlled trials in fibromyalgia (3) (4) (5) (6). In general, the results for SSRIs in fibromyalgia have been similar to the results for other pain conditions. The newer, more potent SSRIs (e.g. citalopram) seem to be less efficacious than the older SSRIs, perhaps because the latter have noradrenergic activity at higher doses. (7)

Muscle relaxants and sleep medicines

If you have stiffness, or spasms, in your muscles as a result of fibromyalgia, your GP, or health professional, may prescribe a muscle relaxant to help ease your symptoms and are commonly taken at bedtime.

Muscle relaxants that are often used for fibromyalgia include medicines called tizanidine (Zanaflex) and methocarbamol (Robaxin). Tricyclic antidepressants (see above) can also help to relax your muscles.

Muscle stiffness and spasms can also affect your ability to sleep, but even if you sleep all night, you may find that you still wake up feeling tired. This is because fibromyalgia can prevent you from sleeping deeply enough to fully refresh you.

If this is the case, your GP, or health professional, may recommend, or prescribe, an over-the-counter sleep medicine, or herbal supplement, in order to help you sleep more deeply. If these medicines do not help, using one of the muscle relaxant medicines mentioned above may help you to sleep more deeply at night because they have a sedative (sleep-inducing) effect.

There are also stronger medicines, such as zopiclone and zolpidem, which can help you sleep. However, you may only be able to use one of these medicines for a short period of time because long-term use can end up disrupting your sleeping patterns even further.

Anti seizure medications

These are a new development in the treatment of fibromyalgia and in the case of Pregablin (trade name Lyrica) have been officially licensed for use in the United States for FM treatment.Pregabalin is an anti-seizure medicine that has been found to be effective in treating several fibromyalgia symptoms, including pain and sleeping problem. However, pregabalin can cause a number of side effects, such as dizziness, blurred vision, and weight gain, so it may not be suitable for everyone.

The other anti seizure medication being trialed for FM is Gabapentin (trade name Neurontin)

FM licenced medications

In America three medications have been licensed for the treatment of fibromyalgia, Cymbalta, Savella (milnacipran) and Lyrica all received licenses for fibromyalgia but they have not been granted the same status in the UK.

Cymbalta and Lyrica in the UK have licenses for neuropathic pain (and Cymbalta for depression). Savella is not licensed in the UK. Not receiving a UK a license for these drugs does not mean that a British GP is unable to prescribe them, but it is "off-license" so if anything serious was to go wrong in terms of drug reactions etc. the GP would have to carefully justify his/her actions. In Scotland SIGN (which is their version of NICE) seem to have a bit more clout and have recommended that neither be prescribed. There is nothing stopping you lobbying your GP to ask if he or she will prescribe you Cymbalta and Lyrica to see if it can help your symptoms.

Cymbalta

Cymbalta (trade name Duloxetine) is a serotonin-norepinephrine reuptake inhibitor manufactured and marketed by Eli Lilly. On October 19, 2006, Eli Lilly issued a press release saying they had done trials which found that Cymbalta, at 60 mg once or twice daily, significantly reduced pain in more than half of women treated for fibromyalgia (FM), with and without major depression, according to 12-week data presented at the annual meeting of the American College of Rheumatology.

Duloxetine is superior to many other medications for the treatment of fibromyalgia due to its freedom from muscarinic, histaminergic and adrenergic adverse reactions. Its effectiveness in pain relief is believed to be due to its modulation of the nociception system. A meta-analysis of clinical trials has confirmed its pain relief, fatigue reducing properties as well as its effectiveness in improving physical and mental performance. (8)

In the study testing the efficacy of Cymbalta for FM, participants completed several questionnaires to measure the amount of pain and discomfort the disease caused them at the beginning of the study, and then at the end of each of the first two weeks and every second week for the remaining 12 weeks of the study. Researchers also tested the participants for depression. (9)

Women who took Cymbalta had significantly less pain and discomfort than those who took the placebo. For men, who made up only 11% of the study, there was no effect from taking the medication compared with a placebo. Reportedly, depression played no part in whether or not the drug worked to control pain. The change in the level of women's pain was particularly pronounced after a month of taking the drug, then leveled off a bit before dropping again near the end of the study. (9)

However, in one of the primary measures of pain there was no significant difference between the two groups at the end of the 12-week trial. Also, because the trial lasted only 12 weeks, it is impossible to tell how well the drug would control treatment for a longer period of time. (9)

The Food and Drug Administration regulators approved the drug for the treatment of fibromyalgia in June 2008 for Americans.

Lyrica

Pregabalin (trade name Lyrica) an anticonvulsant drug was originally used for neuropathic pain and as an adjunct therapy for partial seizures. It was designed as a more potent successor to gabapentin. Recent studies have shown that pregabalin is effective at treating chronic pain in disorders such as fibromyalgia. (10)

In June 2007, pregabalin became the first medication approved by the U.S. Food and Drug Administration specifically for the treatment of fibromyalgia.

It is considered to have a low potential for abuse, and a limited dependence liability if misused.

Savella

In 2009 Milnacipran (trade name Savella) a new SNRI (serotonin and norepinephrine reuptake inhibitor). produced by Cypress Bioscience became the third medication to be approved by the US in as many years.

It is similar to duloxetine (Cymbalta), in that both drugs increase the supply of serotonin and norepinephrine (chemical messengers, also known as neurotransmitters) available to your brain. The difference is that milnacipran gives your brain a larger boost in norepinephrine. Neuroscientists refer to this property of milnacipran as "norepinephrine selectivity."

Many studies have demonstrated that pain receptors tend to be hypersensitive in people with fibromyalgia. By exerting a stronger effect on norepinephrine than on serotonin, milnacipran may scale back the brain's exaggerated reaction to neurochemicals associated with painful sensations.

If your doctor prescribes milnacipran for your fibromyalgia symptoms, you'll typically start with a low dose. Then, under your doctor's guidance, you can gradually work up to 100 milligrams (mg) a day, usually in two separate 50 mg doses. The dose can go up to 200 mg a day if your symptoms don't improve.

Future Medication for fibromyalgia - Xyrem

In America Sodium Oxybate (trade name Xyrem) is gaining a lot of publicity in the affect it is having with helping FM sufferers . This looks a promising new drug but it is expensive and it contains a substance with a history of abuse, so any restrictions will be very strict. Clinical trials of JZP-6 (the active ingredient in Xyrem) showed that it significantly improved sleep quality and reduced pain in fibromyalgia patients. JZP-6 is a central nervous system depressant and is thought to help the patient attain the deeper stage 3 and stage 4 levels of sleep. Daniel J. Clauw, MD, professor of medicine in the Division of Rheumatology at the University of Michigan, said he felt that sodium oxybate represents an exciting new approach to fibromyalgia, addressing an important part of the brain that is not targeted by other therapies.

"This uniqueness of this drug is probably not simply that it is working in part by improving sleep, because other drugs, such as tricyclics and gabapentin/pregabalin, are also likely working in part by improving sleep," he said. "The more exciting property is that this drug is likely working by elevating GABA levels, and that makes it somewhat unique because none of the other drugs that are approved or commonly used for fibromyalgia are likely to be primarily working on this neurotransmitter, which is one of the key inhibitory neurotransmitters in the brain."In January 2010 Decision Resources, one of the world's leading research and advisory firms for pharmaceuticals was predicting that Xyrem will account for more than 15 percent of the fibromyalgia drug market in 2018 in the United States, France, Germany, Italy, Spain, the United Kingdom and Japan.

In March 2011 European regulators have turned down Xyrem as a treatment for fibromyalgia.UCB which in-licensed the drug from Jazz Pharmaceuticals, currently markets Xyrem (sodium oxybate) in the European Union for the treatment of narcolepsy with cataplexy.However it has now been informed by the Committee for Medicinal Products for Human Use of the European Medicines Agency informed UCB that the treatment will not be recommended as a treatment for fibromyalgia.Iris Loew-Friedrich, chief medical officer at UCB, said that "upon discussions and following oral explanation with the CHMP, we have to accept that Xyrem in fibromyalgia syndrome will not be recommended for approval in the EU near-term". She added that the firm is very disappointed with the decision given the significant unmet medical need "and the consistently positive Phase III clinical trials with Xyrem in the indication".

No medication has been approved in Europe to date for the treatment of fibromyalgia. and Jazz' bid to get approval for Xyrem in this indication also failed spectacularly last October. The US Food and Drug Administration sent the company a complete response letter and demanded additional clinical studies and more information about ensuring safe use.

What to do next

Your doctor is there to help you so look at the medications you are currently being prescribed for your fibromyalgia and check in the charts below which symptoms they are targeting specifically.(Remember that your medication might be listed under its generic name or a brand name.) For example if you the feel that pain issue is being addressed you could chat to your doctor about prescribing another medication to help with your sleep symptoms. If you are lucky enough to have a progressive doctor then you could ask about their advice regarding the newer medications like Lyrica and Cymbalta.

Understand there is no magical pill that will get rid of all fibromyalgia symptoms.

Experiment with your doctor to determine which medicines can help “control” your symptoms.

Responsibly use analgesics and narcotics to take the edge off the pain. These medications will not relieve all your pain but may improve symptoms and comfort.

Educate yourself about expectations of medication.

Use the lowest effective dose of medicine; wean off whenever possible (and discontinue any medication that is not working).

Be flexible with medications. Keep it simple.

NHS Direct
http://www.nhs.uk/Conditions/Fibromyalgia/Pages/Treatment.aspx

Medication Dictionary:
http://www.nlm.nih.gov/medlineplus/druginformation.html



(1) (Muller, W.; T. Stratz (2004. Scand J Rheumatic Suppl. 119: 44–48. PMID 15515413.

(2) Arnold LM et al. (2000) Antidepressant treatment of fibromyalgia. A meta-analysis and review. Psychosomatics 41: 104–113

(3) Goldenberg DL et al. (2004) Management of fibromyalgia syndrome. JAMA 292: 2388–2395

(4) Capaci K and Hepguler S (2002) Comparison of the effects of amitriptyline and paroxetine in the treatment of fibromyalgia syndrome. Pain Clinic 14: 223–228

(5) Anderberg UM et al. (2000) Citalopram in patients with fibromyalgia—a randomized, double-blind, placebo-controlled study. European Journal of Pain 4: 27–35

(6) Norregaard J et al. (1995) A randomized controlled trial of citalopram in the treatment of fibromyalgia. Pain 61: 445–449

(7) Fishbain D (2000) Evidence-based data on pain relief with antidepressants. Ann Med 32: 305–316

(8) Acuna C (October 2008). "Duloxetine for the treatment of fibromyalgia". Drugs Today 44 (10): 725–34.

(9) "Duloxetine: new drug. For stress urinary incontinence: too much risk, too little benefit". Prescrire Int 14 (80): 218–20. December 2005

(10) Crofford LJ, Rowbotham MC, Mease PJ, et al. (2005). "Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial". Arthritis Rheum 52


Pain Killers
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Paracetamol
Reduce mild pain Yes Simple analgesic - Non opioid
Tramadol Zydol Reduce mild pain Yes Simple analgesic - Non opioid
Nefopam Acupan Reduce mild pain Yes Simple analgesic - Non opioid
Ibuprofen Brufen Headaches
Tendonitus
Yes Non steroidal anti inflamatory
(NSAIDs)
NSAIDs can be helpful in reducing pain that flares up with excessive physical activity, tendonitis, or bursitis, and should be used only as needed

Dopamine Agonists
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Pramipexole Mirapex Paticularly good with Restless leg symptoms and cluster headaches Yes Dopamine Agonist Designed originally for Parkinsons.Side effects - confusion, double vision ,dream disturbances or trouble with sleeping

5 - HT3 Receptor Agonists
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Tropisetron Navoban NO HT3 Receptor Agonists Used mainly as an antiemetic to treat nausea and vomiting following chemotherapy, although it has been used experimentally as an analgesic in cases of fibromyalgia

Anti depressants
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Amiltriptyline
(most commonly prescribed FM medication in the UK)

Mild pain and sleep help Yes Tricyclic Anti-depressant May cause- Dry mouth, Drowsiness,Constipation.
Can cause extreme sedation and morning hangover effect
Nortriptyline Allegron Muscle relaxant Yes Tricyclic Anti-depressant Some patients feel this has fewer side effects than Amiltriptyline but gives the same benefit
Dosulepin Prothiaden Muscle relaxant Yes Tricyclic Anti-depressant May cause- Dry mouth, Drowsiness,Constipation
Duloxetine Cymbalta Helps sleep
Helps pain
Helps depression
Yes SSNRI Licensed in the UK for neuropathic pain unlike the US where it is licensed for FM.Side effects nausea, headache, dry mouth, insomnia, constipation, fatigue, diarrhea, decreased appetite, dizziness and somnolence
Venlafaxine Efexor Helps fatigue
Helps depression
Helps cognitative impairment
Yes SSNRI Side effects: nausea, headache, dry mouth, insomnia, constipation, fatigue, diarrhea, decreased appetite, dizziness and somnolence
Citalopram Cipramil Helps depression and anxiety Yes Selective Serotonin reuptake inhibitors
(SSRIs)
All SSRIs help with mood but may not adquately deal with pain and sleep disruptions.They also all have discontinuation issues
Fluoxetine Prozac Helps depression and anxiety Yes SSRI See above plus SSRIs have fewer side effects than the tricyclics, although they can cause sexual dysfunction and weight gain
Paroxetine Seroxat Helps depression and anxiety Yes SSRI See above
Milnacipran Savella Helps pain NO SSRI Licenced in US for FM

Muscle relaxants
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Tizanidine Zanaflex Mild pain, sleep, stiffness help Yes Muscle relaxant You need to monitor liver enzymes closely
Carisoprodol Soma Pain help NO Muscle relaxant Causes daytime fatigue

Sleep medicines
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Zopiclone Zimovane Sleep help Yes Non-hypnotic benzodiazepine It is recommended that zopiclone be taken on an "as needed" basis. Daily or continuous use of the drug is not usually advised
Zolpidem Stilnoct Sleep help Yes Short-acting nonbenzodiazepine May cause amnesia, hallucination and delusions

Anti seizure medications
Generic Name Trade Name Fibromyalgia Useage Available in UK Drug Type Comments
Pregabalin Lyrica Pain help
Sleep help
Yes Anti seizure Licensed in the UK for neuropathic pain unlike the US where it is licensed for FM
Gabapentin Neurontin Pain help
Sleep help
Yes Anti seizure Is viewed as less potent in FM than pregabalin