Making your day-to-day lives easier through fibromyalgia treatments

Those living with fibromyalgia tend to experience a diminished quality of life due to pain, poor sleep patterns, mood swings, and memory issues. The condition is similar to those experiencing chronic fatigue syndrome and is characterized by persistent, widespread pain. Unfortunately, the root causes of fibromyalgia are still a mystery, making treatment focused on pain relief and treating symptoms of depression.

The most effective drugs for treating fibromyalgia symptoms are: pregabalin, duloxetine, and milnacipran. Among other treatments, the most effective for improving sleep, fatigue, and quality of life is amitriptyline, a tricyclic antidepressant.

Other treatments with unproven clinical benefits include:

• SSRI antidepressants (fluoxetine, paroxetine)
• opioids (tramadol, oxycodone)
• cannabinoids
• antiepileptics (clonazepam, phenytoin)
• muscle relaxants (cyclobenzaprine)
• intravenous lidocaine
• growth hormone

3 proven fibromyalgia medications

1. Pregabalin, an antiseizure medication that blocks calcium channels, is also more effective for treating fibromyalgia pain than gabapentin, phenytoin and other drugs in this group.
2. Amitriptyline is scored as the most effective for managing sleep and depression symptoms, but it has a lower impact on pain symptoms. Other tricyclic antidepressants (TCAs) showed lower effectiveness.
3. Duloxetine, a serotonin-noradrenaline reuptake inhibitor (SNRI), is more effective for fibromyalgia treatment than other drugs in this class, such as milnacipran or (des)venlafaxine. A recent analysis of randomized clinical trials showed that duloxetine has a stronger impact on pain and depression than milnacipran and other SNRIs.

How to find out which medications work best for you

For starters, always keep in mind the various factors that can affect how you respond to medications. One factor is genetic variations in liver enzymes. This can play a crucial role in metabolism and of many drugs. This alone can impact the effectiveness of medication, how your body tolerates it, and the risk of any side effects. You may metabolize this medication slower or faster than the average person, which impacts the clinical effect. Faster metabolism means the drug is circulating for a shorter period, reducing its effectiveness. Alternatively, a slower metabolism can lead to accumulation of the drug in your bloodstream, potentially causing drug-induced toxicity.

It’s not so black and white, however:

You can be a fast metabolizer for one enzyme and a slow metabolizer for another – without a genetic test, your doctor would have to guess which medication would work best. Less than 35% of people in North America have normal activity of CYP2D6 and CYP2C19 enzymes, both of which impact amitriptyline clearance. Duloxetine is also primarily metabolized by the CYP2D6 enzyme. That’s why it’s necessary to adjust drug selection and dosing based on your DNA to ensure optimal treatment outcomes.

How can I avoid drug-induced side effects?

Fibromyalgia patients often require multiple medications to effectively manage symptoms, as a single drug may not be enough. This is why it’s crucial to be aware of potential drug interactions and undesired side effects. For example, amitriptyline and duloxetine should not be taken together due to the risk of drug-drug interactions. Instead, either drug can be used along with pregabalin. Additionally, amitriptyline should not be combined with milnacipran and other SNRIs or SSRIs due to the increased risk of serotonin syndrome.

Opioid painkillers, particularly tramadol, frequently do not work well when combined with antidepressants. Opioids could increase the risk of serotonin syndrome and other side effects, so they should not be used with duloxetine and other SNRIs. It’s worth noting that cannabinoids can also significantly influence the metabolism of amitriptyline through the CYP2C19 and CYP3A4 enzymes.

Knowledge is power

To better understand how your body processes medications, you and your doctor should consider a pharmacogenetic test, a type of DNA test, for drug response. Pillcheck is an excellent option as it includes a medication review by a clinical pharmacist who provides recommendations based on your profile and checks for drug-drug interactions.

Alternative fibromyalgia treatments

In addition to medication, alternative treatments can also be beneficial:

• Physical activity incorporating moderate aerobic exercise, yoga, tai chi, or hydrotherapy/swimming could help reduce pain and depression symptoms.
• Acupuncture is also effective in reducing pain symptoms. Cognitive behavioural therapy can help you develop coping skills.
• Mindfulness-based stress reduction and combination therapies reduce fibromyalgia symptoms and are recommended in conjunction with pharmacological treatment.

Summary

Amitriptyline, duloxetine, pregabalin, and milnacipran are proven to effectively improve sleep, fatigue, and pain symptoms in patients who have fibromyalgia. However, caution should be taken when considering other therapies that have a lower clinical impact. Additionally, DNA testing can help you and your doctor determine how your body processes medications, ultimately aiding in selecting optimal drugs and doses.

References

Farag HM et al., Comparison of Amitriptyline and US Food and Drug Administration–Approved Treatments for Fibromyalgia JAMA Netw Open. 2022;5(5):e2212939. doi:10.1001/jamanetworkopen.2022.12939.

Roie Tzadok and Jacob N. Ablin Current and Emerging Pharmacotherapy for Fibromyalgia Pain Res Manag. 2020: 6541798.

Migliorini F at al., Duloxetine for fibromyalgia syndrome: a systematic review and meta-analysis. Surg Res. 2023 Jul 17;18(1):504.

Cuenca-Martínez F et al., Exercise-based interventions on sleep quality in patients with fibromyalgia syndrome: An umbrella and mapping review with meta-analysis. Semin Arthritis Rheum. 2023 Aug;61:152216.