What are the recommended medications for treating fibromyalgia?

Pharmacological Treatment for Fibromyalgia

The most effective medications for fibromyalgia are amitriptyline, duloxetine, milnacipran, and pregabalin, which should be selected based on symptom profile and used as part of a comprehensive treatment approach that includes non-pharmacological interventions. 1, 2

First-Line Medications

• Amitriptyline (10-50 mg/day) is recommended for pain reduction and improved function, particularly beneficial for patients with sleep disturbances due to its sedating properties 1, 2
• Duloxetine (60 mg/day) is FDA-approved for fibromyalgia and particularly effective for pain reduction, functional improvement, and associated depression 1, 3
• Milnacipran (100-200 mg/day) is FDA-approved for fibromyalgia management with effectiveness for pain reduction and fatigue symptoms 1, 4
• Pregabalin (300-450 mg/day) is FDA-approved for fibromyalgia and effective for pain reduction and sleep improvement 1, 5

Medication Selection Algorithm

1. For predominant pain with sleep disturbance: Start with pregabalin (75 mg twice daily, titrate to 300-450 mg/day) or amitriptyline (10 mg at bedtime, titrate to 25-50 mg/day) 2, 5
2. For pain with depression/anxiety: Start with duloxetine (30 mg daily for 1 week, then 60 mg daily) 2, 3
3. For pain with significant fatigue: Consider milnacipran (12.5 mg daily, titrate to 50 mg twice daily) 2, 4
4. For inadequate response to monotherapy: Consider combining medications from different classes (e.g., pregabalin plus duloxetine) 2, 6

Dosing and Administration

• Pregabalin: Begin at 75 mg twice daily for one week, then increase to 150 mg twice daily (300 mg/day); may increase to 225 mg twice daily (450 mg/day) if needed 5
• Duloxetine: Start at 30 mg daily for one week, then increase to 60 mg daily; no evidence that higher doses provide additional benefit 3
• Milnacipran: Begin with gradual titration to minimize side effects, targeting 100 mg/day (50 mg twice daily) 4
• Amitriptyline: Start at low dose (10-25 mg) at bedtime, may gradually increase to 50 mg if tolerated 2

Efficacy Considerations

• Recent research shows duloxetine may provide the most significant improvements in pain, quality of life, and sleep quality compared to pregabalin and milnacipran 7
• Pregabalin demonstrates rapid and clinically significant improvements in pain and sleep but may be less effective for overall quality of life 8
• Most patients remain on the same dose throughout treatment, with only about 20% continuing therapy for ≥1 year 9

Important Monitoring and Precautions

• Pregabalin: Monitor for dizziness, somnolence, peripheral edema, and weight gain; requires dose adjustment in renal impairment 5, 10
• Duloxetine: Watch for nausea, dizziness, and dry mouth; taper gradually when discontinuing to avoid withdrawal symptoms 3
• Amitriptyline: Monitor for anticholinergic effects, sedation, and cardiac effects, particularly in older adults 2
• All medications: Regularly reassess efficacy and tolerability; discontinue gradually rather than abruptly 2, 3

Medications to Avoid

• Corticosteroids are not recommended for fibromyalgia treatment 1
• Strong opioids are not recommended and have not demonstrated benefits for fibromyalgia 1, 2

Treatment Pitfalls

• Starting with full therapeutic doses rather than gradual titration increases side effect burden and discontinuation rates 2
• Failing to address sleep disturbances, which can amplify pain perception 2
• Relying solely on pharmacological therapy without implementing exercise and behavioral approaches 2
• Not providing adequate patient education about the chronic nature of fibromyalgia 2