What are the first line medications for fibromyalgia?

First-Line Medications for Fibromyalgia

Duloxetine, pregabalin, and amitriptyline are the first-line medications for fibromyalgia, with duloxetine showing the most significant benefits for pain, quality of life, and sleep quality. 1, 2, 3

Evidence-Based Medication Options

First-Line Options:

1. Duloxetine (SNRI)

   • Dosage: Start at 30 mg once daily for 1 week, then increase to 60 mg once daily 1
   • Benefits: Effectively reduces pain, improves function, and addresses depression 2, 1
   • FDA-approved specifically for fibromyalgia 1
   • Most effective for improving pain, quality of life, and sleep quality 3
   • Common side effects: Dizziness, sedation, nausea 1

2. Pregabalin (Anticonvulsant)

   • Dosage: 300-450 mg/day (divided doses) 2, 4
   • Benefits: Reduces pain and improves sleep quality 2, 3
   • FDA-approved for fibromyalgia 4
   • Better tolerated than duloxetine with fewer discontinuations 3, 5
   • Side effects: Dizziness, somnolence, weight gain 2

3. Amitriptyline (Tricyclic Antidepressant)

   • Dosage: 10-50 mg/day 2
   • Benefits: Reduces pain and improves function 2
   • Long history of use in fibromyalgia with established efficacy 2
   • Side effects: Dry mouth, constipation, sedation 2
   • Caution in older adults due to anticholinergic effects 1

Second-Line Options:

1. Milnacipran (SNRI)

   • FDA-approved for fibromyalgia 1
   • Particularly effective for fatigue symptoms 3, 5
   • Less effective for sleep disturbances compared to duloxetine and pregabalin 5

2. Cyclobenzaprine (Muscle Relaxant)

   • Similar structure to tricyclic antidepressants 2
   • Moderate evidence for effectiveness 2
   • Helpful for sleep disturbances 2

Treatment Algorithm

1. Initial Assessment:

   • Evaluate predominant symptoms (pain, sleep disturbance, fatigue, depression)
   • Check for contraindications to specific medications
   • Consider comorbidities

2. First-Line Selection Based on Symptom Profile:

   • Pain + Depression: Duloxetine (60 mg/day) 1, 3
   • Pain + Sleep disturbance: Pregabalin (300-450 mg/day) or Amitriptyline (10-50 mg/day) 2, 5
   • Pain + Fatigue: Duloxetine or Milnacipran 3, 5
   • Older adults: Avoid amitriptyline; prefer duloxetine or pregabalin 1

3. Monitoring and Adjustment:

   • Assess response after 4-6 weeks
   • If inadequate response, consider:
     • Dose optimization
     • Switching to alternative first-line agent
     • Combination therapy (though evidence is limited) 6

Important Clinical Considerations

• NSAIDs and opioids are not recommended for fibromyalgia as they have not demonstrated benefits and carry significant risks 7, 2
• Sodium oxybate received a strong recommendation against use due to safety concerns 2
• Non-pharmacological approaches should be used concurrently, including:
  • Heated pool treatment (strong evidence) 2
  • Individually tailored exercise programs 2, 1
  • Cognitive behavioral therapy 2, 1

Common Pitfalls to Avoid

1. Dosing errors: Higher doses of duloxetine (>60 mg/day) do not provide additional benefit but increase side effects 1

2. Abrupt discontinuation: Always taper medications gradually to prevent withdrawal symptoms 1

3. Overlooking contraindications:

   • Duloxetine: Avoid in severe renal impairment (GFR <30 mL/min) and liver disease 1
   • Amitriptyline: Use with caution in older adults and patients with cardiac issues 1
   • Pregabalin: Monitor for weight gain and cognitive effects 2

4. Inadequate trial duration: Allow sufficient time (4-6 weeks) before determining treatment failure 2

5. Monotherapy expectations: No single medication addresses all fibromyalgia symptoms effectively 6, 8