In the previous articles I covered the development, risk factors and the diagnosis of the fibromyalgia syndrome (FMS). In this article I will outline the drugs used in treatment for FMS. I’ve seen that there are already numerous discussions about them in the forum.
General Treatment Considerations
Unfortunately drug treatment in FMS is not as clear-cut as with other diseases. This is because FMS is a syndrome with different underlying causes (e.g. physical, psychological stress, trauma) and not a disease entity. It is often regarded as the common end-point of chronic stress from different origins.
For this reason it is important to apply treatment according to different subgroups of FMS. These subgroups are distinguished by key symptoms and the underlying causes for chronic stress or “stress vulnerability”. They include factors like biographic background, personality traits (e.g. perfectionism, anxiousness, hyperactivity), actual psychological and/or social distress, inadequate coping (catastrophizing) and accompanying psychiatric disorders (e.g. depression, anxiety).
Therefore there is no single ideal treatment. Rather, a patient-tailored multi-component therapy should be established in a stepwise approach. These components include pharmacological and non-pharmacological treatments and there are different levels of evidence. This makes the whole process a bit complex and might explain difficulties in implementation. Initial approach should always include education, exercise and drug monotherapy.
Antidepressants: Best evidence (“first-line drugs”) and experience clearly exists for the antidepressants amitriptyline (Elavil©, Vanatrip© at min. 10mg/d) and duloxetine (Cymbalta© at 60mg/day). This is because certain transmitters (dopamine, serotonine, norepinephrine) affected in depression play a role in pain processing too and are supposed to “modulate” pain processing . Also, the emotional network in the brain is closely intertwined with the pain network. Effects in studies showed an improvement of pain by 25-50% (superior to placebo) after 12 weeks of treatment . Despite these study results, “real-world-experience” shows that the majority of FMS patients do not achieve great benefit from any single medication and side effects (dry mouth, fatigue) can be strong. Direct patient surveys showed no or moderate benefit of antidepressants in FMS patients. Other antidepressants can be used as second line treatment but with less evidence.
Antiepileptic drugs: These drugs (“second-line drugs”) have shown to affect pain processing in the brain and are sometimes used in FMS and include gabapentin (Neurontin©1200-2400mg/day) and pregabalin (Lyrica© at 300-450mg/d). Effects on pain improvement after 12 weeks were similar but side effects stronger. The evidence from studies is weaker and therefore the recommendation differs from country to country. Interestingly, due to study limitations, the European Medicines Agency (EMA) has denied approval for duloxetine and gabapentin for the treatment FMS whereas in the US the FDA approved them.
Analgesics: Classic Pain killers like NSAIDs or paracetamol have not shown to be very effective and should be avoided for long term (>12 weeks) use. Complications (kidney damage and stomach ulcers) are far too problematic. Narcotics (opioids) should be avoided at all cost because over long term they can increase pain sensitivity and lead to a multitude of complications.
These include patient education, exercise (aerobic and strengthening), relaxation, cognitive behavioral therapy and mind-body interventions (yoga, meditation, tai chi) and will be covered in the next article.
I hope this was informative so far. I know, information on drugs can be confusing and the benefit and side effects vary individually. It’s important for you to become your own expert on how they effect you. Notice that studies used the time of 12 weeks to assess efficacy, not two weeks like in depression.
You’re most welcome to share your experiences with drugs or ask questions here.