What medications are used to treat fibromyalgia?

Medications for Fibromyalgia Treatment

The most effective FDA-approved medications for fibromyalgia are pregabalin, duloxetine, and milnacipran, with pregabalin being the first drug specifically approved for fibromyalgia management. 1, 2

First-Line Pharmacological Options

• Pregabalin (300-450 mg/day) is FDA-approved for fibromyalgia and effectively reduces pain and improves sleep quality (Level Ia, Grade A evidence) 1, 2
• Duloxetine (60 mg/day) is recommended for pain reduction, functional improvement, and associated depression (Level Ia, Grade A evidence) 1
• Milnacipran (100-200 mg/day) is effective for pain reduction and fatigue symptoms (Level Ia, Grade A evidence) 1
• Amitriptyline (10-75 mg/day) is recommended for pain reduction and improved function, particularly beneficial for patients with sleep disturbances due to its sedating properties (Level Ia, Grade A evidence) 1

Medication Administration and Titration

• For pregabalin, start with low doses (25-50 mg at night) and gradually increase to minimize side effects such as dizziness, somnolence, and cognitive dysfunction 3
• Divide pregabalin's daily dose into two or three equal doses to improve tolerability 2, 3
• Monitor for dose-related side effects including weight gain and peripheral edema with pregabalin 3
• For amitriptyline, start with 10 mg at bedtime and gradually increase to 25-50 mg as tolerated 1, 4

Medication Efficacy and Expectations

• Pregabalin demonstrates multidimensional effects in fibromyalgia, with rapid and clinically significant improvements in pain and sleep 5
• Only about 50% of patients with fibromyalgia will respond adequately to pregabalin at approved dosages 6
• Most patients remain on the same dose throughout treatment, with >60% not requiring dose increases 7
• Treatment durability has been demonstrated for at least 6 months in pregabalin responders 6

Treatment Continuation and Adherence

• Only about one-fifth of patients continue their initially prescribed medication (amitriptyline, duloxetine, gabapentin, or pregabalin) for ≥1 year 7
• Pregabalin should be discontinued gradually to avoid withdrawal symptoms 3
• Regular reassessment of pain levels, function, and side effects is essential to evaluate treatment efficacy 1

Important Precautions and Monitoring

• Monitor pregabalin-treated patients for emergence or worsening of depression and suicidal thoughts 3
• Pregabalin can be safely combined with other medications due to its lack of protein binding and negligible hepatic metabolism 3
• Use caution when combining pregabalin with central nervous system depressants as it may worsen sedation 3
• Adjust pregabalin dosage in patients with renal insufficiency 1

Medications to Avoid

• Corticosteroids are not recommended for fibromyalgia treatment 1, 4
• Strong opioids have not demonstrated benefits for fibromyalgia and are not recommended 1, 4
• Nonsteroidal anti-inflammatory drugs (NSAIDs) have not shown significant benefits for fibromyalgia 4

Comprehensive Treatment Approach

• Medications should be used as part of a broader treatment approach that includes non-pharmacological interventions 1
• Aerobic and strengthening exercise has the strongest evidence (Level Ia, Grade A) and should be implemented alongside medication therapy 1
• Cognitive behavioral therapy is particularly beneficial for patients with concurrent mood disorders 1
• Patient education about the chronic nature of fibromyalgia is crucial for setting realistic expectations 1