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Fibromyalgia – Pharmacological Treatment Options

Nov 29, 2015 2:00 PM

Dear Community,

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.

Pharmacological Treatments

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.

Non-pharmacological treatments
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.

Kind regards

Nov 29, 2015 2:39 PM

@ Dr. Fouradoulas, thank you so much for taking the time to talk to us about fibromyalgia, it truly helps to know this information. We really appreciate everything you do to keep us aware of the latest news,medicines, facts etc. I love reading what you post because it's very informative. Have a great day.

Nov 29, 2015 7:29 PM

So, what advice do you have when it comes to patients with a history of personality/psychological disorders, when the docs won't try anything until you agree to antidepressants.

I've read their side effect profiles, and having had severe anxiety and depression, plus a history of insanity or just developmental disorders in my family, I am uncomfortable trying a med that lists suicide, increased pain, don't take with x diagnosis (several of which I have) and hallucinations as side effects.

Why do docs push these meds? I've explained the family history but some just won't listen!

Nov 29, 2015 8:24 PM

Thank you Dr fouradoulas. This was very informative and helpful. It is gonna help me be more patient with my lyrics I'm on I've been on a turn key dose increase for four weeks now started at 75 and now I'm up to 150. I've only been on the night dose for a week but according g to your article I've got to give it 12 weeks to see if its gonna work. I had begun to doubt whyy doct scheduled my follow up so far out but now its clear. It's scheduled at that time frame. Its hard to wait that long when u hurt everyday but at least I understand the math behind it. Thank you for time and effort in this. And being willing to help us. I appreciate you.

Nov 30, 2015 3:11 AM

ferretbandit, psych counseling should be possible without the use uf drugs. Combined its just more effective, until you stopp them again. Sounds a bit like blackmail, your story. I would go the other way, antidepressants only if you agree to psychotherapy.
The side effects listed just contain every symptom collected in the studies, for safety reasons. Look for the most "frequent" ones.

Different doctors/ countries, different attitudes. Some push, some don't. Have you asked them?

Nov 30, 2015 8:50 AM

Yes, I've asked. Some refuse to answer, others say they have patients who've been helped. I just don't understand why my GP is owing for them. Sorry if it sounded like black mail, it's really fear because meds have sometimes triggered worse personality disorders in my family. It's just a scary thought for me.

Ironically, the psychologists don't think I should be on antidepressants, just my old GP.

Nov 30, 2015 9:42 AM

I could not get any sort of treatment until taking anti depressants age 40. I kept telling my then doctor I hurt like hell and was told it was depression, even though another doctor said I had fibro at approx 38. Chart notes include me being "hostile" because I didn't want anti depressants. It took another 6 years...yes 6, years to get any fibro meds and only because the pain was so bad I laid in bed crying looking like I was having seizures.

A FMS patient has no rights what so ever in deciding or choosing the best route to take when it comes to meds. If you take a stance you stop in the spot without any further options until you do what the doctor wants. This is WRONG! How wrong? Amitriptyline made me suicidal at 24 and after numerous dumb attempts (pills, hanging attempt etc) I drove my car into a tree at 45 mph. The doctor refused to take me off them even though this is a well known side effect. Ironically I discovered my birthcontrol was changing my personality and ended oral birthcontrol and had no more "depression" this is one of the numerous reasons I am against anti depressants. Last year I was given cymbalta (i am on 4 or 5 other anti anxiety /depressants). The cymbalta did not react well with me. I swear I hurt worse on it and the nausea was horrific and debilitating. After a couple weeks I told my doctor what was going on and I didn't think I could take it anymore. The question was...are you sure you want to eliminate an option? I was guilted into trying 2 more weeks like I don't want to feel better. It got worse and finally I had to stop. The next time I was at the doctor, and I really like my doctor, I was told since I couldn't take cymbalta there were no other options.

I said this in another post but it is worth saying again. Doctors need to step up they are making FMS patients worse. The battle with the medical field wears and tears you down. Let me count the ways...not listening, not hearing, not believing, treating you like a hypochondriac, believing depression is an illiness not a normal reaction to a situation, believing fms comes alone, they stop looking at any other causes for pain because every pain is fibro and depression, they pump you full of meds the list goes on. How much is the handful of pills taken multiple times a day making the FMS worse? But you get the million pills because if you hurt it is depression. So if you break a bone just remember it doesn't hurt you are just depressed.

I wish I had the strength, energy and lack of pain to be a patient advocate. Not everyone can speak up, I however obviously do not have that issue and have "fired" more than one doctor as me and my insurance didn't need to pay them for bad service.

Nov 30, 2015 10:32 AM

Ferret bandit I think he meant it sounded like you were being blackmailed when you said doctors won't agree to anything unless you try anti depressant meds.

Nov 30, 2015 12:04 PM

Shammagren, I had the same exact reactions on the cymbalta, after its been on it 6 months. Suddenly the pain was much worse and my mental state took a nosedive where I wanted to die. I recognized it and spoke to a doc who took me off, but too fast so I got the hellish withdrawals.

Nov 30, 2015 2:02 PM

There is a cymbala law suit you migh research. I on the other hand take a higher dose and it helps my disease.

Nov 30, 2015 4:14 PM

Dr. F thank you for all the information on FMS. The medications I take is 50 mg Fentonyl Patches, 800 mg Gabapentin 4 x day, Hyrocodone / Acetaminophen 325 / 7.5 every 6 hrs as needed for pain, 100 mg Savella 2 x day. I also take 3 look pressure meds, famotidine 40mg 2 x day,Raloxifene 60mg x1 day. Plus I take a lot of vitamins and minerals due to Gastric Vertical Sleeve Surgery, I have herniated disk, I have severe pain in my neck owhere I had an anteriordiskectomy on C5,6,7 with a titanium plate, and screws. Is there anything I can take that will not raise my seriton levels any higher than they already are. Thank you again for taking time out of your busy schedule to enlighten all of us about FMS.

Nov 30, 2015 4:41 PM

Weezie, you're on maximum dosages. Some doctors just increases the dose if pain remains and neglect coping. Again, narcotics are legitimate temporarily only or in chronic cancer pain. Gabapentin works well for neuropathic pain. The rest is trial & error. Are drugs the only option for you?

Nov 30, 2015 4:45 PM

Wait, Dr. F, are you specifically just talking about Fibro when you are talking about narcotics or are you speaking in general terms - that they should be used only temporarily unless you r a cancer patient.

Nov 30, 2015 4:48 PM

I have not only FMS but Syringomyelia, Osteoarthritis and degenerative disk disease as well as some others I take the Gabapentin and the Savella for my nerve pain.

Nov 30, 2015 4:55 PM

I have tried yoga but due to my knees being so severely damaged I can't stand to put any weight on them even to get up off the floor without being in unimaginable pain. I have thought about pool therapy, but my husband usually needs our one vehicle when I can go to the gym to use the pool.

Nov 30, 2015 7:01 PM

Crps, I'm not one to sue, at least not without major life compromising issues that I couldn't afford the treatment on my own. And honestly, with my Issy of sooooo many allergic reactions & sensitivities, I can't say it was the med specifically. Maybe it was my genetic defect that caused it as much as the med. I survived with no real harm. But thanks for letting me know about it. 🙏🌼

Dec 01, 2015 6:54 PM

Dr F, I have just been put on Naltrexone 3mg once daily, I have had to stop Tramadol SR150mg twice daily in order to take this new medication. I have tried antidepressants Lyrica and Cymbalta which did not work.
Any suggestions you have would be fantastic.😕 Thank you

Dec 10, 2015 12:02 PM

Amy, sorry for the late reply. I didn't get a notice. Yes, I speak in general terms, not only FMS. In the past, narcotics were given for all kinds of chronic pain, similar to steroids. Nowadays we know that there are longterm side effects and even pain sensitization and spreading. Therefore it should remain a temporary strategy. I know it is disappointing to hear but we can't trick the body over long term with drugs.

Dec 10, 2015 12:07 PM

Outchithurts, I can't give individual recommendations here, only general. I would have to know your entire story. You can send me a question with your background through ask the expert.

Dec 10, 2015 12:18 PM

I appreciate your posts Dr and you make me long to be drug free. I made it a week using medical marihuana instead and because weather is more stable here even started 30min AM yoga. But I seem to feel a ridiculous ant of pain from soreness that ended up w me taking the Vicodin last night. I am so discouraged! But I just can't seem to let the Vicodin go yet 😔

Dec 10, 2015 2:41 PM

Dr. F, you keep saying things like "we know this" in regards to opioid usage. How do you know this? I can say from 35 years of personal experience with horrible constant pain and doctors trying to treat it that I have heard nothing of what you say "we know". Clearly, I am not a doctor, but you would think that one of my many doctors would have mentioned this to me. Are there long term studies we can read? Articles? TED talks or videos we can watch?

I really have very very few options but pain medications. I have:
1. Constant & flaring burning pain from nerve damage in and around my bladder & genitals
2. A massive amount of extremely tight scar tissue
3. Severe Uterine Prolapse
4. Endometriosis
5. Vulvadynia
6. Pelvic Pain
7. Interstitial Cystitis
8. Osteoarthritis in the area where they had to break and set my pelvis
9. Hip stiffness & pain
10. Constant UTI's

Physical nerve blocks, shots in the nerves of the back, ablations, Calmare, excising of the bladder, etc have all been put on the table then taken back off. I am on:
1. Gabapentin 3600mg a day
2. Vesicare 10mg (1 tab daily)
3. Duloxetine 60mg (1 once daily)
4. OxyContin ER 20 mg (1 tab 3 times a day)
5. Oxycodone 5 mg (2 tab tid)
6. B-12 1000mg
7. Uricalm 200mg 2-3 times a day (Piridium/Phenazopyridine)
8. PreLief 2 tabs a day (Calcium 260mg/Phosphorous 200mg)
9. Cysta MD 540mg (2 caps at night) {Quercetin, Bromelain, Papain, Cranberry, Wood Betony Leaf, Passionflower, Valerian Root}

The only things that really seem to help at all are my pain pills, the Cysta MD & ice/things that numb. Antibiotics, Cipro really, helps when the baby UTI's inevitably grow up.

I am virtually bed bound due to the pain. If I didn't have the Oxy's I would kill myself. They're the only pain medicine that seems to help at all. Unfortunately, my doctor refuses to adjust the dosage that I'm on - in fact when I requested just that he grew angry & frustrated and began shouting at me & verbally attacking me.

I know I am not the only one in this type of situation. What else am I supposed to do? I would like to try Medical Marijuana but I don't have one of the extremely few diagnosis's required. I have had hypnosis suggested to me. My stepfather used hypnosis to stop smoking.

What would you suggest to someone like me? What else is there? Am I and others like me doomed to a future of being looked down upon with suspicion & scorn by doctors who think we're addicts, pharmacists that think they're better then us and give us a hard time, friends & family who don't understand because all the media depicts are addicts? I've never seen any program about Chronic Pain patients and their struggles.

It's sad and unjust. I guess I find it a bit presumptuous and cruel to completely ignore an entire subset of medication that a lot of people like me rely on to survive. To even get out of bed or take care of family.

What are we supposed to do?

Dec 12, 2015 3:56 PM

Amie, I'm sorry to see that you are going through that much pain and suffering. If there was a simple solution for chronic pain, you would already know it. Did you go to pain management? What books did you read about chronic pain? Please take a look at my other article about non-pharmacological treatments. Again, treatment must be individual and multi-component, not all patients react the same way. Sometimes inpatient rehabilitation is helpful. Hypnosis is a great option if you can find an experienced practitioner. Meditation is great for finding balance and acceptance. There are lots of alternative body treatments you can try like acupuncture, craniosacral, shiatsu, body talk etc. There's a lot of power in Belief and positive expectation, placebo studies have proven that. On the other side, catastrophizing like being "doomed" leads to worse outcomes. Why not use affirmations? Conventional medicine has it's limits and we need to acknowledge that and not put too much expectation into drugs only. Here's an article about narcotics and long term effects: http://ceaccp.oxfordjournals.org/content/early/2013/09/26/bjaceaccp.mkt045.full.pdf+html
There
are different attitudes towards prescribing narcotics and psychopharmacological drugs, especial between countries. I've heard US doctors are more generous..
Hang in there and see where it leads you to.
best wishes

Nov 03, 2017 2:44 PM

Do we really believe fibro is not a disease entity? Studies show changes in cell chemistry & cerebral spinal fluid in people with fibro. A hyperactive adrenal system with over production of fight or flight chemistry can be linked to chronic stress resulting in muscle tension & pain. What about pain that occurs when there is very little stress or that occurs with changes in atmospheric pressure such as when it rains or becomes very cold. My point is research continues on this disease as yes it is a disease in its own right and that fact is foundational to its treatment. And the empathic understanding needed by medical professionals in working with those of us who have it. I truly resent being lump into a subgroup with those who have inappropriate personality traits, coping mechanisms & psychiatric disorders. I have learned positive stress responses and coping mechanisms & yet have more pain now than ever. Therapeutic stretching, exercise & a single drug is a poor iinitial approach to treatment. Addressing sleep deficets, metabolic/nutritional health, and yes pharmacologic interventions plural. Using herbal substitutions where possible. & alternative treatment modalities is for me the better baseline for treatment. A good Naturalpathic practitioner as part of a treatment team developed by the patient with assistance from their PCP is paramount.
Why Dr Marc do you not agree with the growing research as foundation to this less judgemental more comprehensive and empathic approach to fibro.? You seem such a kind man(As it comes through in your writing). What new research do you know that keeps you from embracing the treatment approach outlined by currently researching medical practitioners such as Dr. Geneirva Lipman who has a practice dedicated to fibro patients. Something in your education on the topic of fibro has seemed to have led you to believe this disease has a primary phyciatric cause. That belief is so offensive & unreasonable to me.

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