John J. Cush, MD

Disclosures

May 15, 2001

Question

I have a patient with fibromyalgia (FM) who is being treated with 20 mg fluoxetine (Prozac) and 50 mg amitriptyline (Elavil) per day. She is not better after 2 months. What is the best antidepressant treatment for patients with FM?

Response from John J. Cush, MD

Treatment of FM is complex and often frustrating because diagnosis and treatment may be significantly delayed in many cases, and because many treatments are ineffective for most patients. Moreover, there are few objective, well-done clinical trials to guide us on the most appropriate therapy. Most investigators believe that treatment of FM requires a multifaceted approach that specifically addresses: (1) pain control with simple analgesics; (2) improvement of sleep; (3) stretching exercise (eg, water exercise, water aerobics, yoga); and (4) control of depression, if present. Interestingly, fewer than 20% of patients with FM will demonstrate evidence of major depression, although many more will at times show depressive symptoms or poor coping skills.

Antidepressant drug use had been a major advance in the treatment of FM. Antidepressants are used for either control of depressive symptoms or as adjunctive agents in pain management. Both the tricyclic (TCI) antidepressants (eg, amitriptyline, trazodone) and the selective serotonin reuptake inhibitors (SSRIs, eg, paroxetine, fluoxetine, sertraline, venlafaxine) have been clearly shown to be effective antidepressants when used at appropriate doses. The TCIs and SSRIs are equally effective, although some evidence suggests that SSRIs are better antidepressants and TCIs are better pain modulators. Both classes have been used to modulate nociceptive responses in patients with neuropathic pain or chronic pain disorders such as FM, chronic low back pain, migraine headache, and phantom-limb pain. Unfortunately, data are still inadequate to answer your question, "What is the best antidepressant for patients with FM?" Both amitriptyline and fluoxetine have been tested in controlled trials and demonstrated some efficacy. Venlafaxine was tested in an 8-week, open-label trial of 15 patients with FM; 6 (55%) of the 11 patients who completed the trial experienced a 50% or more reduction in FM symptoms.

My advice is to maximize the treatment of depression in any patient with FM and depression because poorly or inadequately treated depression will undermine all other therapeutic interventions. If tolerated, higher doses of antidepressants (eg, fluoxetine 40 mg per day, venlafaxine 150-225 mg per day, or trazodone 200-400 mg per night) may be more effective in some patients.

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