What is the recommended treatment for fibromyalgia, including dosage and potential side effects of milnacipran (Serotonin-Norepinephrine Reuptake Inhibitor)?

From the Guidelines

The recommended treatment for fibromyalgia involves a multifaceted approach including medication, exercise, and cognitive behavioral therapy, with milnacipran being one of the FDA-approved medications, typically started at 12.5 mg once daily and gradually increased to a target dose of 50 mg twice daily. According to the EULAR revised recommendations for the management of fibromyalgia 1, the management of fibromyalgia should aim at improving health-related quality of life, balancing benefit and risk of treatment, and often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities.

Key Recommendations

• The initial management should focus on non-pharmacological therapies, including aerobic and strengthening exercise, cognitive behavioral therapies, and multicomponent therapies 1.
• Pharmacological management options include amitriptyline, duloxetine or milnacipran, tramadol, pregabalin, and cyclobenzaprine, with duloxetine or milnacipran being recommended with a weak strength of recommendation for 100% of the working group 1.
• Milnacipran works by increasing serotonin and norepinephrine levels in the brain, which helps reduce pain signals and improve mood.

Dosage and Side Effects

• The typical starting dose of milnacipran is 12.5 mg once daily, gradually increasing to a target dose of 50 mg twice daily (100 mg total daily dose) over a one-week period 1.
• Common side effects of milnacipran include nausea, headache, constipation, dizziness, insomnia, hot flashes, hyperhidrosis, vomiting, palpitations, increased heart rate, dry mouth, and hypertension.
• Patients should also engage in regular gentle exercise, practice good sleep hygiene, and consider cognitive behavioral therapy as part of a comprehensive treatment plan for optimal management of fibromyalgia symptoms.

Comprehensive Treatment Plan

• A comprehensive treatment plan for fibromyalgia should include a combination of non-pharmacological and pharmacological therapies, tailored to the individual patient's needs and preferences 1.
• The plan should aim to improve health-related quality of life, reduce pain and other symptoms, and enhance functional ability.

From the FDA Drug Label

Milnacipran hydrochloride tablets are selective serotonin and norepinephrine reuptake inhibitor (SNRI) indicated for the management of fibromyalgia. Administer milnacipran hydrochloride tablets in two divided doses per day. Based on efficacy and tolerability, dosing may be titrated according to the following schedule: Day 1: 12.5 mg once Days 2 to 3: 25 mg/day (12.5 mg twice daily) Days 4 to 7: 50 mg/day (25 mg twice daily) After Day 7: 100 mg/day (50 mg twice daily) Recommended dose is 100 mg/day. May be increased to 200 mg/day based on individual patient response.

The recommended treatment for fibromyalgia with milnacipran includes a dosage of 100 mg/day, which may be increased to 200 mg/day based on individual patient response.

• The dosage should be titrated according to the following schedule:
  • Day 1: 12.5 mg once
  • Days 2 to 3: 25 mg/day (12.5 mg twice daily)
  • Days 4 to 7: 50 mg/day (25 mg twice daily)
  • After Day 7: 100 mg/day (50 mg twice daily)
• Potential side effects of milnacipran include:
  • Nausea
  • Palpitations
  • Headache
  • Constipation
  • Heart rate increased
  • Hyperhidrosis
  • Vomiting
  • Dizziness
  • Hypertension
  • Insomnia
  • Anxiety
  • Hot flush
  • Dry mouth 2 2 2

From the Research

Recommended Treatment for Fibromyalgia

The recommended treatment for fibromyalgia includes the use of milnacipran, a serotonin-norepinephrine reuptake inhibitor (SNRI) 3, 4, 5, 6, 7.

Dosage of Milnacipran

The dosage of milnacipran for the treatment of fibromyalgia is typically 100-200 mg per day, given in divided doses 4, 5, 6.

Potential Side Effects of Milnacipran

The potential side effects of milnacipran include:

• Nausea
• Headache
• Constipation
• Tachycardia
• Hyper- and hypotension
• Increased risk for bleeding and suicidality in at-risk patients 3, 4, 6

Efficacy of Milnacipran

Milnacipran has been shown to be effective in managing global fibromyalgia symptoms, pain, and improving symptoms of fatigue and cognitive dysfunction 3, 4, 5, 6, 7.

Treatment Approach

Milnacipran works best when used as part of an individualized treatment regimen that includes resistance and aerobic exercise, patient education, and behavioral therapies 3.

Benefits of Milnacipran

The benefits of milnacipran therapy include:

• Modest fibromyalgia pain relief
• Improvement in symptoms of fatigue and cognitive dysfunction
• Effective for fibromyalgia-associated symptoms, including depression
• Well-tolerated in adults with fibromyalgia, with most adverse events being mild to moderate in severity 4, 5, 6, 7