From the Guidelines
For a patient with fibromyalgia who has an allergy to Lyrica (pregabalin), the next best treatment option would be duloxetine (Cymbalta), typically started at 30 mg daily and increased to 60 mg daily after one week. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that has demonstrated efficacy in managing fibromyalgia symptoms, particularly pain and fatigue, as supported by the 2022 CDC clinical practice guideline for prescribing opioids for pain 1. It works by increasing the levels of serotonin and norepinephrine in the brain, which helps regulate pain signals and improve mood. Another alternative would be milnacipran (Savella), another SNRI specifically approved for fibromyalgia, starting at 12.5 mg once daily and gradually titrating to 50 mg twice daily. Tricyclic antidepressants like amitriptyline (10-25 mg at bedtime) could also be considered, though they may have more side effects, as noted in the EULAR revised recommendations for the management of fibromyalgia 1. These medications should be combined with non-pharmacological approaches such as:
- Regular gentle exercise
- Cognitive behavioral therapy
- Stress management techniques for optimal management of fibromyalgia symptoms. Patients should be monitored for side effects such as nausea, dizziness, dry mouth, and potential changes in blood pressure or heart rate. The EULAR recommendations emphasize the importance of a multidisciplinary approach, combining non-pharmacological and pharmacological treatments tailored to the individual patient's needs, as outlined in the 2017 EULAR revised recommendations for the management of fibromyalgia 1.
From the Research
Alternative Treatment Options for Fibromyalgia
Given the patient's allergy to Lyrica (pregabalin), alternative treatment options for fibromyalgia should be considered. The following medications have been studied as potential treatments for fibromyalgia:
- Duloxetine: a serotonin norepinephrine reuptake inhibitor (SNRI) that has been shown to be effective in reducing pain and improving sleep quality in patients with fibromyalgia 2, 3
- Milnacipran: another SNRI that has been approved for the treatment of fibromyalgia and has been shown to be effective in reducing pain and improving functional status 2, 3
Efficacy and Tolerability of Alternative Treatments
Studies have compared the efficacy and tolerability of duloxetine, milnacipran, and pregabalin in patients with fibromyalgia. The results suggest that:
- Duloxetine and milnacipran are effective in reducing pain and improving sleep quality, with duloxetine being superior to milnacipran in reducing depressed mood 2
- Milnacipran is superior to duloxetine in reducing fatigue 2
- The risk of adverse events, such as headache and nausea, is higher with duloxetine and milnacipran compared to pregabalin 2
Considerations for Treatment Selection
When selecting an alternative treatment for a patient with fibromyalgia who is allergic to Lyrica, the following factors should be considered:
- The patient's symptoms and medical history
- The potential benefits and risks of each treatment option
- The patient's preferences and values
- The availability of other treatment options, such as lifestyle modifications and non-pharmacological interventions 4