As of this writing, three medications have been approved by the FDA for the treatment of fibromyalgia: Lyrica (pregabalin), Cymbalta (duloxetine) and Savella (milnacipran). Since all three are relatively new drugs, information on how well they work and their side effects is still being gathered.
Because every patient's symptoms and body chemistry are different, it is often a matter of trial and error to find the best medication for a particular patient with a particular illness. However, a recent German study, which was the first to compare the pros and cons of the three drugs head-to-head, may help doctors choose which medication has the best chance of success for any given patient.
The study authors searched MEDLINE, SCOPUS, Cochrane Central Register of Controlled Trials, and sought unpublished data from the databases of FDA, US National Institutes for Health, and Industry through May 2009 for randomized controlled trials. They found 17 trials that were of high enough quality to be included in this study. These trials included a total of 7,739 patients, almost all of whom were Caucasian women with an average age of 48 to 50.
The purpose of the study was to compare symptom reduction and adverse events (negative side effects). The symptoms they looked at included:
- Sleep disturbance
- Depressed mood
- Health-related quality of life
The researchers found that all three medications reduced pain by at least 30% and improved health-related quality of life. In addition, here is how the medications fared in specific symptom categories:
- Pain – Lyrica and Cymbalta provided more pain relief than Savella.
- Fatigue – Lyrica and Savella were superior in reducing fatigue.
- Sleep disturbance – Lyrica and Cymbalta were the best at reducing sleep disturbances.
- Depressed mood – Savella ranked at the top for reducing depression while Lyrica provided no relief for depression.
As for side effects, Lyrica resulted in fewer headaches and less nausea than either Cymbalta or Savella; and both Lyrica and Savella resulted in less diarrhea than the other two medications.
When your doctor is deciding which medication to prescribe for you, there is more to consider than just symptoms and side effects. Potential interaction with other prescription drugs, over-the-counter medications and supplements you are taking is a very important factor to consider.
For example, Cymbalta and Savella are serotonin and norepinephrine reuptake inhibitors. Therefore, taking them when you are taking other drugs that affect serotonin can put you in danger of developing serotonin syndrome, a very serious and life-threatening condition. Some medications that can affect serotonin include: Ultram (tramadol), triptans (used as a Migraine abortive), MAOIs (a class of antidepressants), and antipsychotics.
How your body metabolizes Cymbalta can be affected by medications that inhibit certain liver enzymes (CYP1A2 AND CYP2D6). And Lyrica could potentially cause convulsions in people who have a seizure disorder.
I was pleased to see this study. While there will still likely be some trial and error involved in finding the best fibromyalgia treatment for each patient, at least this gives doctors and patients a place to start. For instance, while Lyrica scored high in reducing three of the four most frequent FM symptoms, if depression is one of your major symptoms, Lyrica may not be the best drug to start with unless your doctor wants to treat your depression separately. If pain and sleep disturbances are your primary symptoms, then Cymbalta may be a good choice; or if fatigue and depression bother you the most, then Savella could be a good option.
While most doctors are probably going to start treating your FM by trying one or more of these FDA approved medications, if none of them work for you, don't be discouraged. There are a number of other drugs that are often prescribed off-label for FM. Many of them have been through at least some clinical trials for FM treatment but have either not yet received FDA approval or have not applied for approval because they are already available in generic form and it would not be profitable for them to go through the approval process.
For a list of some of these other medications prescribed for FM, see: Medications Prescribed for Fibromyalgia
Finally, the study authors offered a reminder (with which I agree) saying, “pharmacology is only one piece of the puzzle when it comes to successful management of FMS. Aerobic exercise, hydrotherapy, and multicomponent therapy have shown efficacy in alleviating fibromyalgic symptoms without harms, and can be offered to the patient either as [an] alternative or used adjunctively with pharmacological therapy.”
Hauser W, Petzke F, Sommer C. Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome. J Pain. 2010 Jun;11(6):505-21.
Leavitt SB. Meds for Fibromyalgia Compared & Contrasted. Pain-Topics.org. June 4, 2010.