Medications Prescribed for Fibromyalgia
by Karen Lee Richards
Prescribed medications are a key component of most fibromyalgia treatment plans. Since there are currently only three FDA approved medications for fibromyalgia, many medications are prescribed off-label. That means the drug is prescribed for a use other than that for which it is approved. Since numerous studies have been published showing that various medications can be beneficial for people with fibromyalgia, physicians are able to prescribe those medications off-label.
Keep in mind that no single medication works for every fibromyalgia patient. Also, FM patients are often more sensitive to medications than the average person, so great care and consideration should be taken when prescribing drugs for fibromyalgia. Sometimes it's necessary to start with lower doses to prevent adverse reactions. Since it's frequently a matter of trial and error, it's important for the patient and the doctor to work together to find the best possible treatment plan.
Following are the seven categories of medications most often used to treat fibromyalgia:
Analgesics are pain killers. They include:
- Over-the-counter medications like aspirin, acetaminophen, ibuprofen and naproxyn. (Ibuprofen and naproxyn are also anti-inflammatories)
- Nonsteroidal anti-inflammatories (NSAIDs) such as etodolac, nabumetone and Cox-II inhibitors (for example, Celebrex).
- Corticosteroid anti-inflammatories like prednisone and dexamethasone.
- Opioids such as codeine, hydrocodone, oxycodone, morphine and fentanyl.
- Tramadol, a narcotic-like opiate agonist.
Since fibromyalgia is not a true inflammation, anti-inflammatories may be less effective in reducing pain. They can, however, be helpful in reducing pain flares brought on by strenuous physical activity, tendonitis or bursitis. 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.
Recent studies have indicated that opiate pain medications often do not relieve FM pain. It appears that the mu-opioid receptors in people with fibromyalgia have a reduced ability to bind to the drugs targeting them. There is also emerging evidence that over the long term, the use of high-dose opioids may actually increase an FM patient's hypersensitivity to pain.
Tramadol is a synthetic opioid. 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 a controlled substance in the U.S. and many other countries. Thus far studies on the effectiveness of tramadol in relieving FM pain have had quite positive results.
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 may 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.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as 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. Cymbalta received FDA approval for the treatment of fibromyalgia in June 2008. Studies have found that it can reduce pain, improve energy, decrease anxiety, improve depression, and help alertness and concentration with only minimal side effects. It has also been found to be beneficial for FM patients who are not clinically depressed. Savella was approved by the FDA to treat FM in January 2009 and is expected to be in pharmacies by mid-2009. Clinical trials showed that many of the patients taking Savella reported improvements in pain, physical function, and patient global assessment. Remeron is another SNRI that is being used by pain specialists for its ability to promote sleep and it's suspected ability to reduce pain and headache symptoms.
Two anti-convulsant or anti-seizure medications that have been used to treat fibromyalgia are Lyrica and Neurontin. Lyrica has the distinction of being the first medication ever to receive FDA approval for the treatment of fibromyalgia. It 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. The most common side effects were dizziness and sleepiness.
Neurontin has been found to help neuropathic pain. Fibromyalgia patients who have burning or pain that feels like electric shocks in their hands and feet have reported improvement when treated with Neurontin.
4. Muscle Relaxants
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. If 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 if muscle spasms are not the primary problem.
5. Anti-anxiety Medications
Anxiety in fibromyalgia patients can increase pain, muscle tension, irritability and sleep problems. If anxiety is a problem, benzodiazepine medications like Klonopin, Ativan and Xanax can help reduce pain and improve sleep. They work by improving the balance of inhibitory and excitatory receptors in the central nervous system. (Most FM patients have too much activity in their excitatory receptors.) Klonopin taken in the evening can be particularly helpful for patients who have a lot of leg problems, including pain and restless or jerking legs.
6. Sleep Modifiers
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. There are two types of sleep modifiers:
- Benzodiazepines like Restoril can be used to treat insomnia. The biggest concern about using benzodiazepines is their habit-forming potential.
- Hypnotics such as Ambien, Lunesta and Rozerem cause relaxation that helps patients fall asleep and stay asleep. Ambien is less habit forming than the benzodiazepines but can cause rebound insomnia when it is stopped. The newer hypnotics Lunesta and Rozerem are not habit-forming and do not produce rebound insomnia.
The neurologic medication Provigil, originally developed to treat narcolepsy, is sometimes also used to treat the fatigue of fibromyalgia. In a 2006 study, two-thirds of the fibrromyalgia patients taking Provigil experienced a 50 percent reduction in fatigue levels.
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.
© Karen Lee Richards
Last updated 1/26/09