Fibromyalgia Medications

Strong Evidence for Efficacy.

• Amytriptyline 25-50 mg at bedtime
• Cyclobenzaprine 10-30 mg at bedtime
• Pregabalin 300-450 mg / day
• Gabapentin 1600-2400 mg / day
• Duloxetine 60-120 mg / day
• Milnacipran100-200 mg / day.

Weak evidence for efficacy.

• Tramadol 200-300 mg / day
• SSRIs (fluoxetine, sertraline)

SSRIs produce up to a 30% reduction in pain scores and as with other patient populations also works for depression in patients with fibromyalgia. However, SSRIs have not been shown to affect fatigue or sleeping problems.
TCAs are better than SSRIs for treating pain and other symptoms in FM patients.

**Dr. Toby often combines one med from the first group with Tramadol in patients with significant pain issues.

Weak evidence for efficacy: Pramipexole, gamma hydroxybutyrate, growth hormone, 5-hydroxytryptamine, tropisetron, s-adenosylmethionine.

No evidence: Opioids, NSAIDs, benzodiazepines and nonbenzodiazepine hypnotics, melatonin, magnesium, DHEA, thyroid hormone, and antipsychotics (like Quetiapine).

“Pain in fibromyalgia is thought to be due to a centralized pain state. Medications that reduce the activity of neurotransmitters or increase the activity of inhibitory neurotransmitters such as norepinephrine and serotonin work best, and tricyclic antidepressants appear to be most effective (SOR A). Older SSRIs have limited benefit. Oral analgesics only work in about one-third of patients, and opioids may increase hyperalgesia. Corticosteroids are ineffective.” ABFM

Reference

Presentation by pain specialist Dr. Toby, 9/5/2017