Alternative Medications for Fibromyalgia and Chronic Low Back Pain Management
For a 53-year-old female with fibromyalgia and chronic low back pain currently on oxycodone 60mg QID and Lyrica 75mg QHS who did not tolerate Cymbalta, I recommend increasing pregabalin (Lyrica) dose while adding amitriptyline and gradually tapering oxycodone.
First-Line Medication Adjustments
Pregabalin (Lyrica) Optimization
- Current dose of 75mg QHS is subtherapeutic for fibromyalgia
- Increase pregabalin to 150mg BID, then titrate to 225-300mg BID as tolerated 1
- Pregabalin has high-quality evidence for fibromyalgia pain relief, with approximately 22-24% of patients achieving substantial benefit (≥50% pain reduction) 1
- Recent evidence shows pregabalin is effective for both pain reduction and sleep improvement in fibromyalgia 2
- Monitor for common side effects: dizziness, somnolence, weight gain, and peripheral edema 1
Add Amitriptyline
- Start amitriptyline at 10-25mg at bedtime, gradually titrate to 50-75mg as tolerated 3, 4
- Amitriptyline is a first-line treatment for fibromyalgia with grade B evidence 4
- Functions as a pain modulator through inhibition of serotonin and norepinephrine reuptake in descending pain pathways 4
- Particularly beneficial for improving sleep quality, which is often disrupted in fibromyalgia 4, 5
- Since patient didn't tolerate duloxetine (Cymbalta), start with a low dose of amitriptyline to minimize side effects
Opioid Tapering Strategy
Gradual Oxycodone Reduction
- Begin tapering oxycodone by 10% of the original dose every 1-2 weeks 3
- Current evidence does not support opioid use for fibromyalgia 5, 6
- Opioids have shown limited efficacy for chronic low back pain with significant risks 3
- For chronic low back pain, opioids provide only short-term relief (mean difference of about 1 point on a 0-10 pain scale) 3
- Maintain open communication about withdrawal symptoms and breakthrough pain during tapering
Additional Medication Options
NSAIDs for Low Back Pain Component
- Add scheduled NSAID (naproxen 500mg BID or celecoxib 100mg BID) for back pain component 3
- NSAIDs provide effective pain relief for back pain 3
- Consider cyclooxygenase-2-selective NSAIDs (celecoxib) which have lower risk of adverse effects than nonselective NSAIDs 3
- Monitor for gastrointestinal and cardiovascular side effects, especially in patients with risk factors 3
Consider Muscle Relaxants
- Add cyclobenzaprine 5-10mg at bedtime for muscle spasm component 3
- Cyclobenzaprine has shown benefit specifically for fibromyalgia 3
- Similar structure to tricyclic antidepressants, may have synergistic effects with amitriptyline
- Monitor for sedation, dry mouth, and other anticholinergic effects
Combination Therapy Considerations
- Combination of pregabalin with amitriptyline targets different pain mechanisms 3
- This multimodal approach may allow for lower doses of each medication, potentially reducing side effects 3
- Studies show combinations of medications acting at different sites in pain pathways may provide additive benefits 3
- Regular reassessment of pain, function, and side effects is essential to optimize therapy
Monitoring and Follow-up
- Assess pain levels, function, and side effects every 2-4 weeks during medication adjustments
- Obtain baseline ECG before starting amitriptyline, especially given patient's age (53) 4
- Monitor for common side effects: sedation, dizziness, dry mouth, constipation, weight gain
- Evaluate effectiveness using standardized pain and function assessments
- If inadequate response after 8-12 weeks of optimized therapy, consider alternative options such as milnacipran or topical agents
This approach prioritizes evidence-based medications for fibromyalgia and chronic low back pain while providing a structured plan to reduce opioid dependence, with the goal of improving pain control, function, and quality of life.