Mark J. Pellegrino, M.D., is Board Certified in Physical Medicine and Rehabilitation and Electrodiagnostic Medicine, and is one of the nation’s leading experts on Fibromyalgia. Dr. Pellegrino is the author of numerous books and articles on Fbromyalgia, and despite having Fibromyalgia, he maintains an active medical practice with more than 20,000 patients cared for. He was recently named in “Best Doctors in America.” The following article is an updated excerpt from a chapter of
Fibromyalgia, Up Close and Personal by Mark J. Pellegrino, M.D.*
Prescribed medicines are an important part of fibromyalgia treatment. Presently there are no FDA approved medicines for the treatment of fibromyalgia. Many studies have been published, however, that show how numerous prescribed medicines can benefit those with fibromyalgia. Physicians are able to prescribe these medicines off-label for fibromyalgia because of these evidence-based studies.
Pain relief, improved sleep, more energy, and better mood are examples of goals that prescription medicines can help you reach. People with fibromyalgia tend to be more sensitive to medications and often experience side effects such as nausea, drowsiness, or lightheadedness. Lower doses of medicines need to be considered for fibromyalgia. Prescribed medicines can provide great benefits to many, so it is worthwhile to work together with the physician to try to find a successful medicine regimen.
Categories of drugs used in the treatment of fibromyalgia can include:
2. Anti-inflammatory medicines
3. Antidepressant medicines
4. Muscle relaxants
5. Sleep modifiers
6. Anti-anxiety medicines
7. Other medicines used to treat chronic pain.
Analgesics are pain killers and can include over-the-counter medicines such as aspirin and acetaminophen, or prescription-strength pain pills like narcotics (opioids) - ie codeine, hydrocodone, oxycodone, morphine and fentanyl. Tramadol (UltramTM) is a pain reliever that differs from narcotics in its action on the central nervous system.
These medications do not alter the fibromyalgia, but they can help take the edge off of pain by blocking the central pain pathways. Narcotic medications have potential for adverse side effects including drowsiness, difficulty with concentrating, and addiction, so they should be used carefully.
Many people with fibromyalgia are sensitive to codeine medicines, which can cause nausea or an allergic reaction. Tramadol can cause allergic reactions in people sensitive to codeine, and a small number of people taking tramadol have seizures. As a pain specialist, I will frequently prescribe analgesics, including narcotics, for patients experiencing severe pain.
You and your pain physician may sign a written agreement when using scheduled medicines for pain, such as opioids.
2. Anti-Inflammatory Medicines
Anti-inflammatory medicines include aspirin, nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen, naproxyn, etodolac, nabumatone, and the Cox-II inhibitors (i.e., CelebrexTM), and corticosteroids such as prednisone or dexamethasone. These medications are both anti-inflammatory and analgesic.
Some of these medicines, such as ibuprofen, are available both over the counter and by prescription. Because fibromyalgia is not a true inflammation, these drugs may be less effective in reducing pain. However, these drugs can be helpful in reducing pain that flares up with excessive physical activity, tendinitis, or bursitis, and should be used only as needed.
n If the NSAIDs are helpful for overall fibromyalgia pain, they can be continued on a regular basis as long as there are no major side effects.
n The major side effect of the anti-inflammatories is bleeding from gastrointestinal ulcers. This problem is more common the longer the medicine is taken.
n The Cox-II inhibitors (Celebrex) have much fewer side effects to the stomach lining and the kidneys.
n Injectable anti-inflammatories can be considered; these avoid the stomach altogether by getting absorbed intra-muscularly.
I prescribe various types of anti-inflammatories on a regular basis. To avoid risk of bleeding or other side effects, patients must not take over-the-counter anti-inflammatory medicines if they are already taking them by prescription. Sometimes a medicine to protect the stomach lining (called proton pump inhibitors) is recommended along with the anti-inflammatory medicines. [These medicines “inhibit” gastric acid production.]
3. Antidepressant Medicines
The antidepressant medicines include tricyclics (for example, amitriptyline, nortriptyline, doxepin, and trazodone), selective serotonin reuptake inhibitors (ProzacTM, ZoloftTM, PaxilTM, EffexorTM, and CelexaTM), and the selective serotonin and norepinephrine dual reuptake inhibitor (CymbaltaTM). These medicines can treat pain and improve sleep and mood disturbances seen in fibromyalgia. The tricyclic medicines can be effective, but frequent side effects include dry mouth and drowsiness. Using lower doses may decrease side effects.
Because of the extreme sedation and morning hangover effect common with amitriptyline, I’ve found that nortriptyline or trazodone has fewer side effects but gives the same benefit. Even though the sedation side effect of the tricyclic medicine may have worn off by morning, the other benefits of the drugs (decreased pain, muscle relaxation, and improved mood) can continue throughout the day. Because the tricyclic can provide more than one beneficial effect, I think these medicines are handy in fibromyalgia treatment.
The selective reuptake inhibitors work well in treating depression. They also block the breakdown of serotonin, the brain hormone that is low in persons with fibromyalgia and depression. Serotonin is important in the brain’s regulation of pain and sleep. By selectively inhibiting the breakdown of serotonin, these medicines increase the serotonin concentration in the body and its beneficial side effects. These medicines have fewer side effects than the tricyclics, although they can cause sexual dysfunction and weight gain.
Cymbalta is a dual acting antidepressant medicine that has been found to decrease pain in patients with fibromyalgia. It also helps improve energy, decrease anxiety, improve depression, and help alertness and concentration - so this medicine has multiple potential benefits in fibromyalgia. It has been found to help those with fibromyalgia who are not clinically depressed. I have found this medicine to work very well for many of my patients. It is well tolerated. Sometimes there is some nausea and lightheadedness when the medicine is first started, but using a low dose to start reduces the side effects.
Sometimes using a combination of a reuptake inhibitor during the day and a tricyclic at nighttime can be an effective combination medicinal approach. Your physician can help determine what is best for you.
4. Muscle Relaxants
Muscle relaxants can decrease pain in people with fibromyalgia. Medicines in this family include FlexerilTM, SomaTM, SkelaxinTM, and RobaxinTM. The most common side effect is drowsiness, although Soma and Skelaxin cause less of it.
I have found that muscle relaxants do not really decrease muscle spasms or truly “relax” muscles, because the painful area still has palpable spasms. Rather, the medicine appears to help by a central neurological mechanism that reduces muscle pain. If drowsiness is a side effect, this medicine should only be taken in the evening so it doesn’t interfere with driving or concentration. Flexeril is a popular medicine for evening. Although it is a muscle relaxant, it is very similar to amitriptyline in structure and effect, hence the benefits reported.
Medicines in the antispasticity category can be used to treat muscle spasms. Two of these medicines, ZanaflexTM and BaclofenTM, have been shown to help reduce back muscle spasms and pain. Antispasticity medicines are primarily intended for people who have neurologic conditions causing involuntary muscle spasms (such as spinal cord injuries, multiple sclerosis, or strokes). However, they can help patients with fibromyalgia too.
5. Sleep Modifiers
Various medicines can treat insomnia. Medicines already mentioned above can help improve sleep even though they are not classic “sleeping medicines.” Analgesics can help sleep by decreasing the pain that interferes with sleep. Some antidepressants and muscle relaxants can help sleep by causing drowsiness and deeper sleep. Anti-anxiety medicines such as AtivanTM or KlonopinTM can relax the mind and allow better sleep.
True sleep modifiers include benzodiazepines like RestorilTM and the hypnotic non-benzodiazepines such as AmbienTM. The most common reported concern about using sleep modifiers, especially benzodiazepams, is the habit-forming potential. Ambien is reported to be less habit-forming but can cause “rebound insomnia” when it’s stopped. LunestaTM is a newer sleep modifier that is not habit forming and doesn’t cause rebound insomnia. It can cause a metallic taste in the mouth or headaches, but is usually helpful in those patients who tolerate it.
I have found that sleep modifiers improve deep sleep, and particularly improve the morning perception of a good night’s sleep. This improved sleep can carry over into a better day.
Sleep modifiers are short-acting medicines, so they work during the night and are usually eliminated from the body by morning, hence the low chance of a morning hangover. Some people report nightmares with these medicines, but usually these medicines are “silent,” that is, one doesn’t realize any medicine was taken, other than knowing that sleep was better.
6. Anti-Anxiety Medicines
Anxiety is a common problem in fibromyalgia and contributes to pain, muscle tension, and irritability. It can make depression and insomnia worse. Various medicines including antidepressants and muscle relaxants treat anxiety. Benzodiazepines such as Klonopin, Ativan, and XanaxTM, are commonly used medicines. These medicines also cause sedation and thus can improve sleep. Possible side effects include depression and decreased memory. Sometimes it is hard to determine whether symptoms are due to fibromyalgia or are side effects of medication.
I have found Klonopin to be a particularly useful medicine in the evening, especially when there are leg symptoms (pain, restless leg syndrome, jerking of the legs called myoclonus) that interfere with sleep. Low dose Klonopin therapy is one way to improve the balance of the inhibitory receptors (GABA) and the excitatory receptors (NMDA) in the central nervous system.
Most fibromyalgia patients have too much activity in the excitatory receptors (NMDA receptors), and Klonopin can increase the pain inhibitors’ activity to achieve a more normal balance, improving sleep and reducing pain.
7. Anticonvulsant Medicines
This class of medicine includes NeurontinTM (gabapentin) and LyricaTM (pregabalin). Neurontin is an example of a medicine originally used to treat seizure disorders (an anticonvulsant or antiseizure medicine). It was later found to be helpful in treating pain, particularly neuropathic pain. Many people with fibromyalgia who have a lot of burning or electric shock feelings in their hands and feet have improved with a trial of Neurontin.
Lyrica, the "next generation" of Neurontin, was found to be more selective in blocking neuropathic pain and had fewer side effects. Studies have shown it benefits many with Fibromyalgia, so it is a commonly prescribed medicine for this condition.
Other Medicines Used to Treat Chronic Pain
Other medicines can be used to treat pain. Headaches are a common problem with fibromyalgia, and various headache medicines are available. In addition to the medicines described above, headache medicines include ergot alkaloids, sumatriptan, calcium channel blockers, and beta blockers.
Over-the-counter (OTC) products are available as well. In addition to the aspirin, acetaminophen and anti-inflammatory options (ibuprofen, naproxyn), two other OTC products are worth mentioning that may help in fibromyalgia. One is guaifenesin, a mucolytic (mucous dissolving) substance used for congestion. This has been found to support reduced muscle pain in some with fibromyalgia, presumably by acting to support muscle detoxification and excretion of phosphates from the muscles.
Dextromethorphan, the OTC cough suppressant medicine, has also been found to help pain in some with fibromyalgia. This medicine can block pain signals at the spinal cord level. Check with your doctor about any OTC medicines that may be helpful.
In addition to the variety of medicines available for fibromyalgia treatment, a variety of doctor “strategies” are also available. Doctors who prescribe medicine will usually find - through trial and error - an effective and favorite strategy. There is no single right way to prescribe medicines for fibromyalgia, and more than one strategy may work for different people and different doctors. Over the years, I have discovered basic strategies that seem to work best for me when using prescription medicines, and I try to teach my patients some basic medicine goals:
n Understand there is no magical pill that will get rid of all fibromyalgia symptoms.
n Experiment with your doctor to determine which medicines can help “control” your symptoms.
n Responsibly use analgesics and narcotics to take the edge off the pain. These medications will not relieve all your pain but may improve symptoms and comfort.
n Educate yourself about expectations of medication.
n Use the lowest effective dose of medicine; wean off whenever possible (and discontinue any medication that is not working).
n Be flexible with medications. Keep it simple.
* This article is reprinted with permission from the author. It is excerpted from Fibromyalgia, Up Close and Personal, by Mark J. Pellegrino, M.D., Copyright 2005 Anadem Publishing, Inc.
(c) 2005 Mark J. Pellegrino, M.D., and Anadem Publishing, Inc. All Rights Reserved.
Note: This information has not been evaluated by the FDA. It is generic and for general information purposes only, and is not meant to prevent, diagnose, treat or cure any condition, illness, or disease. It is very important that you make no change in your healthcare plan or regimen without researching and discussing it in collaboration with your professional healthcare team.