Fibromyalgia Medications are Not a Cure All

Currently only pregabalin, duloxetine and milnacipran are FDA-approved for use specifically as fibromyalgia treatments. There are other drugs that are used off-label (not FDA approved as treatments) that can be helpful in treating some fibromyalgia symptoms. 

• Pregabalin (Lyrica) has shown some benefits in relieving anxiety, some sleep problems and pain in people with fibromyalgia.
• Another related medication, gabapentin (Neurontin), is sometimes used off-label (meaning it is used for but not FDA-approved for a condition) as a fibromyalgia treatment.
• Duloxetine (Cymbalta) and milnacipran (Savella) are dual-acting norepinephrine and serotonin reuptake inhibitors (antidepressants). They raise levels of neurotransmitters known to prevent pain transmission. 
• Other antidepressants that may provide relief include amitryptiline hydrochloride (Elavil, Endep), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft), but they are not approved specifically for use with fibromyalgia.

Although the approval of duloxetine, milnacipran and pregabalin might seem like progress in the treatment of fibromyalgia, studies suggest that for some people living with this condition, the medications either didn’t provide relief or were stopped due to side effects.
 
“Both physicians and patients should have realistic expectations about the potential benefit of these drugs,” says Winfried Häuser, MD, an associate professor of psychosomatic medicine at the Klinikum Saarbrucken in Germany. “Although patients may initially experience symptom relief with good tolerance, the majority will ultimately discontinue therapy because of inadequate response or unacceptable side effects.”

Side effects of pregabalin include weight gain, swelling, dizziness and drowsiness, among others. Both duloxetine and milnacipran have been known to cause nausea, drowsiness, dry mouth, constipation and increased sweating. Remember that medications affect everyone differently. It’s important to work with your doctor on weighing the benefits and risks of each of your medications.

“Even though I have had a few patients experience modest benefits from them, I rarely prescribe these medications,” says Robert Keenan, MD, MPH, an assistant professor of rheumatology at Duke University School of Medicine. “Many of my patients experience significant weight gain and other side effects that counteract any benefit they might see otherwise.”

In addition to the FDA approved drugs, doctors also use other medications to treat fibromyalgia by managing symptoms such as pain, fatigue and sleep challenges, including:

• Analgesics, including tramadol (Ultracet, Ultram)
• Muscle relaxants, such as cylobenzaprine (Cycloflex, Flexeril)
• Fatigue medications, such as modafinil (Provigil)

 

“In the absence of a single gold standard medication, patients are treated with a variety of drugs from different categories, often with limited evidence,” Dr. Häuser says.

If a patient isn’t responding to drug treatment after four weeks, it should be stopped. Dr. Häuser believes physicians should be discouraged from treating fibromyalgia with medication alone and should also incorporate exercise and counseling into their approach.

Carmen Gota, MD, a rheumatologist at the Cleveland Clinic in Ohio agrees that a multidisciplinary approach is essential in treating fibromyalgia patients.

“Drugs alone are not sufficient,” Dr. Gota says. “You have to look at the whole patient and combine treatment with aerobic exercise and a comprehensive approach that includes cognitive-behavioral therapy and occupational therapy.”

Although studies show that a well-rounded plan helps fibromyalgia patients, Dr. Keenan says that in many of his patients, their attitude is their best asset.

“My patients with a positive mental approach to their fibromyalgia typically do better than those who focus on the negative,” says Dr. Keenan. “A good attitude can take you a long way.”