By Karen Lee Richards*
Most fibromyalgia treatment plans include one or more prescription medications. Unfortunately, no single drug works for every person with fibromyalgia, so discovering which medications work best for each individual patient can be largely a matter of trial and error.
Since FM patients are often more sensitive to medications than the average person, it’s important to start with lower doses, which can be gradually increased as needed, to prevent adverse reactions. It is essential that FM patients and their doctors work together to formulate the best possible treatment plan.
There are currently three FDA-approved drugs for the treatment of fibromyalgia – Lyrica (pregabalin), Cymbalta (duloxetine) and Savella (milnacipran). However, a number of other drugs are also prescribed off-label for FM – typically analgesics, antidepressants, anticonvulsants, muscle relaxants, anti-anxiety medications, sleep aids and sometimes narcolepsy medications.
FDA-Approved Drugs for Fibromyalgia
Lyrica – Marketed by Pfizer Inc., Lyrica is an anticonvulsant that was previously approved to treat seizures, diabetic peripheral neuropathy (pain from damaged nerves that can happen in people with diabetes) and post-herpetic neuralgia (pain following the rash of shingles). Lyrica is thought to work on fibromyalgia by acting on chemicals in the brain that send pain signals across the nervous system, thus calming down overly sensitive nerve cells.
Cymbalta – Marketed by Eli Lilly and Co., Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor antidepressant (SSNRI) that was previously approved to treat depression, anxiety, and diabetic peripheral neuropathy. Cymbalta blocks the neurotransmitters serotonin and norepinephrine from re-entering cells, thereby increasing their levels in the rest of the body. This process is thought to improve mood and reduce pain in people with fibromyalgia. Be aware, however, that discontinuing Cymbalta may result in severe withdrawal symptoms.
Savella – Marketed by Forest Pharmaceuticals, Inc., Savella is a selective serotonin and norepinephrine reuptake inhibitor antidepressant (SSNRI) and was the first drug introduced primarily for treating fibromyalgia. Savella’s method of action is similar to that of Cymbalta except that Savella exerts a stronger effect on norepinephrine than on serotonin. It is thought that this may scale back the brain’s exaggerated reaction to neurochemicals, which is associated with painful sensations.
Drugs Prescribed Off-Label for Fibromyalgia
Other medications that are sometimes prescribed for fibromyalgia generally fall into one of seven categories.
Analgesics (pain killers)
Analgesics (pain killers) include:
- Over-the-counter medications like aspirin, acetaminophen, ibuprofen and naproxyn. Aspirin, ibuprofen and naproxyn are nonsteroidal anti-inflammatories and may cause gastrointestinal distress, including ulcerations and bleeding. Acetaminophen is a pain reliever and fever reducer that works by changing the way the body senses pain and by cooling the body.
- Nonsteroidal anti-inflammatories (NSAIDs) such as etodolac, nabumetone and Cox-II inhibitors like Celebrex. Because many of the NSAIDs carry a serious risk of gastrointestinal bleeding and some also have a cardiovascular risk, they should be taken with great caution and care.
- Corticosteroid anti-inflammatories like prednisone and dexamethasone. While corticosteroids are not considered to be effective for fibromyalgia, they may be prescribed for patients who have other pain conditions, like lupus or arthritis, in addition to FM.
- Opioids such as codeine, hydrocodone, oxycodone, morphine and fentanyl. Although some studies have found that opioids are not particularly effective for fibromyalgia because the mu-opioid receptors in people with fibromyalgia have a reduced ability to bind to the drugs targeting them, many patients who have severe pain insist opioids are the only medications that help.
- Tramadol is a narcotic-like opiate agonist. Although it is described as “opiate-like” and is considered an opiate agonist, it differs from other opioids in the way it acts on the central nervous system. Unlike other opioids, it is not considered to be a controlled substance by the federal government in the U.S., however, a number of states have classified it as a controlled substance.
Antidepressants are often among the first treatment options tried for fibromyalgia patients because they can improve sleep, reduce pain and help mood disturbances. There are three categories of antidepressants:
- Tricyclics – like amitriptyline, nortriptyline and trazodone – can be effective and were the favored FM treatment for many years. However, because of frequent side effects such as dry mouth and the “morning hangover” effect, newer types of antidepressants are often considered to be preferable.
- Selective serotonin reuptake inhibitors (SSRIs) – like Lexapro, Paxil, Zoloft, Prozac and Celexa – increase the serotonin concentration in the body (which is low in FM patients) by blocking the breakdown of serotonin. Because SSRIs can be particularly effective in treating depression, they may be a good choice for fibromyalgia patients who also suffer from depression. On the downside, SSRIs can cause sexual dysfunction and weight gain.
- Selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) – like Cymbalta, Effexor and Savella – are the newest and perhaps most promising class of antidepressants to be used in the treatment of fibromyalgia. They increase both serotonin and norepinephrine concentrations in the body by blocking their breakdown.
Two anticonvulsant or anti-seizure medications commonly used to treat fibromyalgia are Lyrica and Neurontin.
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- Lyrica works by affecting chemicals in the brain that send pain signals across the nervous system. In clinical trials, Lyrica reduced pain and improved sleep, fatigue and general health perception in 30 to 40 percent of FM patients.
- Neurontin is known to help neuropathic pain. Fibromyalgia patients who have burning or electric-shock-like pain in their hands and feet have reported improvement when treated with Neurontin.
Muscle relaxants like Flexeril, Soma, Skelaxin and Robaxin are sometimes prescribed for fibromyalgia pain. Although they may not actually stop muscle spasms, they appear to have a central neurological mechanism that reduces muscle pain. The most common side effect is drowsiness.
When muscle spasms are a particular problem, antispasmotic medications such as Zanaflex and Baclofen can be helpful in reducing the spasms and the pain. Since Zanaflex seems to be effective in improving sleep, blocking pain and reducing headaches, it is sometimes prescribed even when muscle spasms do not seem to be the primary problem.
Anxiety can increase pain, muscle tension, irritability and sleep problems for FM patients. If anxiety is a problem, benzodiazepine medications like Klonopin, Ativan and Xanax can be helpful in reducing pain and improving sleep. They work by improving the balance of inhibitory and excitatory receptors in the central nervous system. When taken in the evening, Klonopin can be particularly helpful for those who have a lot of leg problems, including pain and restless or jerking legs.
The inability to get deep, refreshing sleep is a major problem for most people with fibromyalgia. Although many of the medications already discussed can help improve sleep, sometimes a medication specifically designed to induce sleep is necessary. Sleep-modifying medications include:
- Hypnotics – like Ambien, Lunesta and Rozerem – cause relaxation that helps patients fall asleep and stay asleep. Ambien and Lunesta affect chemicals in your brain that may become unbalanced and cause sleep problems. Rozerem works by affecting certain substances in your body that help regulate your “sleep-wake cycle.”
- Benzodiazepines – like Restoril and Halcion – are an older class of sleep medication used to treat insomnia. These drugs stay in the system longer than the hypnotics, which means they can cause some drowsiness the next day. Another big concern with using benzodiazepines is that they can cause dependence, meaning you may need to stay on the drug indefinitely in order to sleep.
There are two drugs originally developed to treat narcolepsy that are sometimes prescribed for fibromyalgia.
- Provigil is a central nervous system stimulant that increases wakefulness and daytime alertness. It is sometimes prescribed to treat the fatigue of FM. Some patients report that although Provigil seems to work extremely well at first, its effectiveness tends to fade when used regularly.
- Sodium oxybate (Xyrem) is a powerful central nervous system depressant that promotes a deeper level of sleep. Although several large clinical trials have shown sodium oxybate to be effective in improving FM symptoms, thus far the FDA has declined to approve it for the treatment of fibromyalgia. Due to its high potential for abuse, sodium oxybate is strictly regulated. Patients taking it must take part in the “Xyrem Success Program.” Prescriptions are only allowed to be dispensed in the U.S. by a single central pharmacy.
* Karen Lee Richards is ProHealth’s Editor-in-Chief. A fibromyalgia patient herself, she co-founded the nonprofit organization now known as the National Fibromyalgia Association (NFA) and served as its vice-president for eight years. She was also the executive editor of Fibromyalgia AWARE, the very first full-color, glossy magazine devoted to FM and other invisible illnesses. After leaving the NFA, Karen served as the Guide to Fibromyalgia and Chronic Fatigue Syndrome for the New York Times website About.com, and then for eight years as the Chronic Pain Health Guide for The HealthCentral Network.
Pellegrino, M (2005). Fibromyalgia: Up Close & Personal. Anadem Publishing.
Ervin, J.E., Dyer, D., Fox, C. (2007, Sept. – Nov.). “Medication Update.” Fibromyalgia AWARE, 14, 60-61.
“Living with Fibromyalgia, Drugs Approved to Manage Pain.” U.S. Food and Drug Administration. January 31, 2014.
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