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Fibromyalgia

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of fibromyalgia.

Alternative Names

Fibromyositis; Fibrositis; Myofascial pain syndrome

Medications

To date, the FDA has not approved any drug for specific treatment of fibromyalgia. The first choice in drug treatments usually consists of an antidepressant or a muscle relaxant. The goal is improving sleep and pain tolerance. Medications from other drug classes (sleeping aids, anti-convulsants, pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies.

Antidepressants

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve a patient's sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses are necessary for relief of fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Like all medications, tricyclics must be taken as directed. Overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors (SSRIs). Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. In any case, they do not have any significant effect on tender points. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) . These drugs are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin.

• Duloxetine (Cymbalta) is gaining attention as a treatment for fibromyalgia. In a 2004 study, 207 patients with fibromyalgia were randomized to receive either duloxetine 60 mg twice a day or placebo for 12 weeks. Duloxetine significantly improved pain and tenderness and was effective for both depressed and non-depressed patients. Duloxetine was most effective for women, but very few men were enrolled in this trial.
• Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with the SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart when taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
• Milnacipran (Ixel) is under investigation and is not yet approved in the U.S. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. A first Phase III trial evaluating its use as a potential treatment for fibromyalgia was completed in July 2005. While the results of this trial were not statistically significant, the manufacturer is now conducting a longer, larger Phase III trial. Results are expected to be announced in 2007. In a 2004 study of 125 patients, milnacipran improved fibromyalgia pain and other symptoms, including fatigue, sleep, and depression.

Muscle Relaxants

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. Drowsiness is the most common side effect. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects including dry mouth and dizziness. A 2004 review of five randomized controlled trials found that patients who received cyclobenzaprine were three times more likely to report improvement in fibromyalgia symptoms than patients who received placebo.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep for patients who suffer from insomnia.

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia.

• Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
• For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), and others.
• Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful in relieving painful areas in other disorders. It may have some value for fibromyalgia patients.
• Opioids, or narcotics, may be used occasionally for certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Narcotics should be used by such patients only if they cannot find relief with other, less potent treatments. Some patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids such as oxycodone (Roxicodone) or morphine sulfate (Duramorph) for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids. The patients should be evaluated periodically for continuing pain relief, side effects, and indications of dependence.
• Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia, according to a 2005 study published in Arthritis and Rheumatism . Pramipexole stimulates production of dopamine, a chemical messenger in the brain. For the randomized controlled study, researchers compared pramipexole with a dummy pill (placebo). After 3.5 months, 36% of those who took pramipexole said they felt much better, compared to 9% of those received a dummy pill. Overall, patients had a 50% or greater decrease in pain.
• A small 2005 study conducted in Spain suggests that the atypical antipsychotic olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine causes unpleasant side effects. Eleven of the 25 patients in the 2005 study dropped out due to weight gain.

Anti-Seizure Agents (Anti-Convulsants)

Anti-seizure drugs, also called anti-epileptics or anticonvulsants, affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. Studies have shown that gabapentin (Neurontin), an anti-seizure medication also approved for postherpetic neuralgia, affects pain transmission pathways and may relieve the pain associated with fibromyalgia. Phase II and III clinical trials are underway.

Pregabalin (Lyrica) is an anti-epileptic drug closely related to gabapentin. The FDA approved pregabalin in 2004 for treatment of nerve pain and diabetic peripheral neuropathy. It is currently in late-stage trials for treatment of fibromyalgia. A 2005 study of 529 patients with fibromyalgia reported that 450 mg per day of pregabalin reduced pain and improved sleep quality and fatigue symptoms. Dizziness and drowsiness were the most common side effects. Study results presented in November 2006 show pregabalin cut fibromyalgia pain by at least 50% in 63% of patients, and the effect was long- lasting. The study, lasting 6 months, was one of the longest controlled studies of pregabalin in fibromyalgia, to date.

Other Investigative Drugs

Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies are suggesting it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Targeting Pressure Points and Stretching Techniques

Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular program. Stretching techniques may also employ injections or cooling agents to inactivate the pressure points so that muscles can be more effectively stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One such technique is known as "spray and stretch." This method uses the following approach:

• The patient must be in a comfortable position.
• The partner presses on suspected tender points and the patient reports any pain.
• The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. These chemicals are not numbing medicines. They cool the blood vessels in the skin to inactivate the tender points. Numbing skin creams do not appear to be effective for this treatment.
• The spray bottle is held upside-down about 12 - 18 inches from the targeted area. The patient's face should be covered if the spray is being used near the head.
• The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of a numbing drug such as lidocaine may be used for particularly painful tender points as an aid to stretching.

• The injection causes intense, but brief, pain in the trigger point. After the medication has taken effect, however, the muscle's ability to stretch is much greater.
• There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.
• In some cases, injections may be needed several times over 6 - 8 weeks.

• Review Date: 12/15/2006
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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