What is the role of medications in the treatment of fibromyalgia and multiple bursitis-tendonitis syndrome?

Updated: Apr 04, 2018
  • Author: T P Sudha Rao, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

The US Food and Drug Administration (FDA) has approved three drugs for use in fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella). [29] Pregabalin is used to reduce pain and improve sleep; it is given at a dose of 450 mg/day. [30]  The antidepressants duloxetine and milnacipran, which are used to relieve pain, fatigue, and sleep problems, are generally used at lower doses than for treatment of depression. [31, 32]

Nonrestorative sleep is a significant problem for patients with fibromyalgia. Initial drug therapy consists of a low-dose sedating tricyclic antidepressant (TCA), usually amitriptyline (5-10 mg) 1 hour prior to bedtime. [33] The dose is titrated upward every 5-14 days as tolerated, using the minimal dose to achieve restorative sleep. TCAs can cause excessive sedation; therefore, sertraline 25 mg in the morning or another of the more activating antidepressants (eg, fluoxetine) can be added. [34] Other less-sedating TCAs (eg, nortriptyline) can be substituted for amitriptyline in the evening if necessary because of sedation.

Gabapentin has been used off-label for fibromyalgia syndrome because of its salutary effects on chronic pain. A clinical trial has shown benefit in fibromyalgia. [35]  

Trazodone can also be particularly helpful for sedation at night and may cause fewer adverse effects than amitriptyline. Doxepin, a non-TCA antidepressant, can be useful in liquid form to titrate at low doses (2-5 mg) for sedation at night. Cyclobenzaprine can relax muscles and can be used as a single dose at night (2.5-10 mg) or, commonly, at 10 mg tid.

Analgesic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful. One controlled trial showed benefits with tramadol (50-400 mg in divided doses) [36] ; however, tramadol used in combination with antidepressants can cause serotonin syndrome and increased sedation. Tramadol may play a role by allowing a 4-week drug holiday from antidepressant therapy to reset neural receptors and, in intermittent therapy, for exacerbations. Avoid long-term use of benzodiazepines and narcotics.

A small study that evaluated low-dose naltrexone (4.5 mg) as therapy for fibromyalgia found that it reduced symptoms by about 30%, while placebo reduced symptoms by only 2%. [37] Another study showed that sodium oxybate could improve symptoms by about 30% (compared with 10% for placebo). [38] However, access to sodium oxybate is restricted in the United States.


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