eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes
Fibromyalgia: Treatment & Medication
Updated: Aug 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Some investigators believe that a successful fibromyalgia rehabilitation program involves a multidisciplinary team of professionals and various modalities individualized for each patient.14 The team should include the physician, a medical psychologist, physical and massage therapists, and an exercise physiologist. These professionals should have expertise in the treatment of soft-tissue disorders.
Traditional therapy or rehabilitation may worsen the patient's symptoms. Monitor the progress of the patient in rehabilitation. As goals are met and symptoms change, modify the rehabilitation prescription to meet the individual's current needs.
- A number of randomized, controlled trials of multidisciplinary treatment and exercise, combined with education and/or cognitive behavioral therapy showed that patients with fibromyalgia had improvements on a 6-minute walk, with significant decreases in pain and beneficial efficacy. One randomized, controlled trial of multidisciplinary rehabilitation showed improvement in health-related outcomes in a nonclinical, community-based setting at 15-month follow-up. A published study that evaluated the impact of a physical therapy–based educational program on patients with fibromyalgia found that the program had a positive impact on patients' well-being.29 The study concluded that the program had no effect on the other symptoms of fibromyalgia.
H ã user et al, in a meta-analysis of randomized, controlled clinical trials, also looked at the efficacy of multidisciplinary fibromyalgia treatment.30 Reviewing 9 studies, which included a total of 1,119 patients, the investigators found evidence that treatment combining at least 1 educational or psychologic therapy with at least 1 exercise therapy can provide short-term reduction in pain, fatigue, and depressive symptoms. The study results also indicated that physical fitness benefits from the treatment can be maintained over the long term. - Numerous modalities, including electrotherapy, cryotherapy, and therapeutic heat, can reduce pain. Teach patients how and when to use therapeutic modalities as part of their maintenance program. One investigator recommends muscle energy treatments, positional release methods, and massage as part of the rehabilitation program to decrease stiffness and pain.
Ekici et al compared the efficacy of manual lymph drainage therapy (MLDT) with connective tissue massage (CTM) in the treatment of fibromyalgia.31 In a randomized, controlled trial utilizing 50 women with primary fibromyalgia, 25 patients were treated with MLDT, with the rest receiving CTM therapy. Both techniques appeared to be useful in reducing pain and improving patients' health status and health-related quality of life. However, patient responses on the Fibromyalgia Impact Questionnaire indicated that MLDT was better than CTM at reducing morning tiredness and anxiety. - Some investigators have found that daily aerobic and flexibility exercises are an essential component of the rehabilitation program.32 Exercise was first recognized to have therapeutic benefits 20 years ago. At that time, patients were randomized to receive 20 weeks of high-intensity exercise or flexibility training. Improvements in fitness, global assessment ratings, and tender-point pain thresholds were greater in the high-intensity group than in the flexibility group. Subsequent clinical trials have confirmed the benefits of aerobic exercise and muscle strengthening on mood and physical functioning.
- Patients should begin with gentle warm-up, flexibility exercises and progress to stretching all of the major muscle groups. Low-impact aerobic exercise is necessary at least 3 times weekly. Patients should always start at low levels of exercise and progress slowly. The goal is to exercise safely without increased pain. The patients' target exercise regimen is 4-5 times a week for at least 20-30 minutes each time; this may take the patient months to achieve.
- Some patients with fibromyalgia may never be able to achieve this level of exercise; encourage them to exercise at the highest level possible without worsening their symptoms. Some investigators believe that aquatic exercise may be the safest and gentlest aerobic conditioning exercise available for this group. Aquatic therapy enables aerobic conditioning and also flexibility, strengthening, and stretching exercise. Aquatic exercise is well tolerated and is especially helpful for some patients.
Other Treatment
Trigger-point injection is an important technique for providing mechanical disruption (myolysis) of the trigger point. Disruption leads to a reduction in pain and an increase in ROM, exercise tolerance, and circulation. Therefore, trigger-point injection is a valuable tool in the treatment of patients with tender points and trigger points.22,33 Long-term outcomes improve when these injections are used in conjunction with physical therapy, massage therapy, or stretching exercises done at home.
Dry needling and needling with infiltration are effective in eliminating trigger points and tender points. Many authors report that needling with infiltration is most effective. Patients with fibromyalgia who receive trigger-point injections have had significant improvement in pain intensity, pain threshold, and ROM. Patients may have a delayed improvement in pain but an immediate improvement in ROM. They may also experience severe soreness that develops soon after the injection and that lasts for a long period.
- A number of materials and techniques are used for needling with infiltration. Most physicians prefer 1% lidocaine without epinephrine or 0.5% procaine. Lidocaine is often chosen over procaine because it has fewer allergic reactions, a faster onset of action, and greater potency. Steroids are generally not indicated or recommended for trigger-point injections in patients with fibromyalgia. Sterile saline can be used in patients who are allergic to local anesthetics.
- When performing a trigger-point injection, use a sufficiently long needle. In most cases, an extensive area must be infiltrated; therefore, a relatively large volume of 2-12 mL is injected. Before injecting the local anesthetic, make certain that the needle is in the trigger point. Localization of the trigger point is ascertained when the needle causes a marked increase in pain with referral pain and/or a fasciculation is seen or felt.
- Several contraindications to trigger-point injections must be observed. Avoid giving these injections to patients with local or systemic infection. Patients with bleeding disorders or those who are taking anticoagulation medication should not receive trigger-point injections without proper medical evaluation, and they should receive these injections only after the risks and benefits are explained clearly to them.
Medication
Patients with fibromyalgia have difficulty tolerating regular doses of most medications and supplements. They are sensitive to medications, and adverse effects are common. To avoid these problems, use the lowest dose available or perhaps one half to one quarter of the lowest recommended dose.
Several medications should be avoided or used carefully. To date, the US Food and Drug Administration has not approved any drug for the specific treatment of fibromyalgia, although pregabalin has been approved for neuropathic pain associated with fibromyalgia, and milnacipran is an antidepressant approved for management of fibromyalgia.
Avoid complications and confusion by providing written instructions and drug information. These instructions need to be easy to understand. Patients should be instructed to consult their physician before starting any over-the-counter (OTC) medications or supplements, to avoid potentially harmful drug interactions.
Classes of drugs
Most investigators recommend using narcotics sparingly. In fibromyalgia without concomitant rheumatic illnesses, steroids are not helpful and should be avoided.
CNS agents, antidepressants, muscle relaxants, or anticonvulsants are the most successful pharmacotherapies. These medications affect serotonin, substance P, norepinephrine, and other neurochemicals that have a broad range of activities in the brain and spinal cord, including the modulation of pain sensation and tolerance.
Nonsteroidal anti-inflammatory drugs (NSAIDs) have not been shown to be effective analgesics when used alone, but when combined with tricyclic agents, they may be useful as analgesics. Guaifenesin had significant benefits in decreasing pain, improving other symptoms, or laboratory parameters in a 12-month, randomized, controlled study.
Data from randomized, controlled trials have not supported the use of thyroid hormones, melatonin, calcitonin, or dehydroepiandrosterone in the treatment of fibromyalgia.
Medications to improve sleep
An effective medication to improve sleep-onset problems is zolpidem. The patient must be given instructions on proper dosing.
Sleep-maintenance disorders are more difficult to manage than are sleep onset problems. In general, antidepressants are most commonly used because of their effect on serotonin. Tricyclic antidepressants have the strongest evidence for efficacy. The criterion standard is amitriptyline, but many patients cannot tolerate this drug.
Trazodone is inexpensive, well-tolerated, and effective. The starting dose is 25 mg, and it should be taken at 8 pm. If necessary, the dose can be slowly up-titrated. If the patient is not staying asleep, adding a serotonin-selective reuptake inhibitor (SSRI) may be helpful.
If the patient has concomitant restless legs syndrome or mitral valve prolapse, clonazepam may be the drug of choice. The starting dose is 0.125 or 0.25 mg taken at 8 pm. Titrate the dose to the lowest effective dose.
Tiagabine increases sleep efficiency with a marked increase in slow-wave sleep in healthy elderly patients. Tiagabine titrated from 2 mg to 12 mg may improve sleep maintenance in some patients.
Gabapentin is being studied. It may also aid in sleep maintenance.
In 1998, pramipexole was described as an excellent treatment for restless legs syndrome. At the 2000 ACR meeting in Philadelphia, the use of pramipexole at bedtime to treat fibromyalgia was first reported. This medication may aid in sleep maintenance in patients with fibromyalgia and restless legs syndrome.
Summary
Medications useful for treating fibromyalgia include the following:
- Sleep problems
- Antidepressants (eg, trazodone, SSRIs, dual-reuptake inhibitors [SNRIs], tricyclic antidepressants)
- Anticonvulsants (eg, clonazepam, gabapentin, tiagabine)
- Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone)
- Muscle relaxants (eg, cyclobenzaprine, tizanidine)
- Dopamine agonists (eg, pramipexole)
- Depression - Antidepressants
- Pain
- NSAIDs
- Muscle relaxants
- Analgesics (eg, tramadol)
- Other
- Vitamins and minerals
- Malic acid and magnesium combination
- Antioxidants
- Amino acids
- Herbs and supplements
Antidepressants
These drugs are used not only to treat depression but also to improve sleep and pain. Antidepressants increase CNS serotonin. Delta-wave sleep also improves. The result is an improvement in the symptoms experienced by patients with fibromyalgia.
Trazodone (Desyrel)
Antidepressant most helpful in patients with anxiety and sleep disturbances.
Adult
Starting dose: 25 mg PO qd, preferably at 8 pm with food; increase dose q3wk but only to lowest effective dose
Pediatric
Not established
May enhance response to alcohol, barbiturates, and other CNS depressants; digoxin and phenytoin serum levels may increase with concurrent trazodone; may decrease hypoprothrombinemic effects of warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Priapism; orthostatic hypotension and syncope; dizziness if taken with empty stomach
Duloxetine (Cymbalta)
Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake.
Adult
Start 30 mg PO qd, then increase to 60 mg PO qd if not effective
Pediatric
Not established
Metabolized by CYP1A2 and CYP2D6; coadministration with drugs that inhibit CYP1A2 (eg, fluvoxamine, cimetidine, ciprofloxacin, enoxacin) may increase duloxetine blood levels and toxicity; coadministration with drugs that inhibit CYP2D6 (eg, paroxetine, fluoxetine, quinidine) may increase duloxetine blood levels and toxicity; duloxetine moderately inhibits CYP2D6 and may decrease elimination of CYP2D6 substrates (eg, tricyclic antidepressants, phenothiazines [eg, thioridazine], type 1C antiarrhythmics [eg, propafenone, flecainide]); coadministration with MAOIs may cause serious, sometimes fatal reactions that include hyperthermia, rigidity, myoclonus, autonomic instability, mental status changes including extreme agitation, delirium, and coma
(see Contraindications)
Documented hypersensitivity; uncontrolled narrow-angle glaucoma; within 14 d of stopping MAOI use (do not initiate MAOIs within 5 d of stopping duloxetine)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing, do not abruptly discontinue; caution with hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence, and increased sweating
Fluoxetine (Prozac)
Antidepressant that inhibits uptake of serotonin by neurons. Used to improve mood and restore normal sleep patterns.
Adult
Starting dose: 10 mg PO qam for 1 wk, then 20 mg PO qam; increase dose q3wk prn in 10-mg increments
Pediatric
Not established
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; concurrent MAOIs or use in the last 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before starting therapy
Venlafaxine (Effexor)
Serotonin/norepinephrine reuptake inhibitor. May treat depression by inhibiting neuronal serotonin and norepinephrine reuptake. In addition, causes beta-receptor down-regulation.
Adult
Immediate release: 75 mg/d PO divided bid/tid with food and increase in 75 mg/d increments q4d to 225-375 mg/d
Extended release: 75 mg PO qd with food and increase in 75 mg/d increments q4d to 225 mg/d
Pediatric
Not established
Cimetidine, MAOIs, sertraline, fluoxetine class I-C antiarrhythmics, TCAs; phenothiazine may increase the effects of venlafaxine
Documented hypersensitivity; patients taking MAOIs or have taken MAOIs within 14 days of initiating therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients on this medication may experience hypertension; fatal reaction may occur if venlafaxine is taken concurrently with an MAOI; exercise caution in patients with cardiovascular disorders; the sustained-release formulation should not be divided, crushed, or placed in water
Amitriptyline (Elavil)
Sedative tricyclic antidepressant helpful in improving mood and restoring sleep. Inhibits uptake of serotonin and norepinephrine.
Adult
Starting dose: 5 mg PO qd at 8 pm; increase over 3 wk prn up to lowest effective dose
Pediatric
<12 years: Not established
>12 years: 10 mg PO tid and 20 mg qhs
Phenobarbital may decrease effects; coadministration with CYP2D6 inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOI use in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid in elderly patients
Milnacipran (Savella)
Selective serotonin and norepinephrine reuptake inhibitor (SSNRI). Exact mechanism of central pain inhibitory action and ability to improve symptoms of fibromyalgia unknown. Indicated for fibromyalgia.
Adult
Day 1: 12.5 mg PO once
Days 2-3: 12.5 mg PO bid
Days 4-7: 25 mg PO bid
After day 7: 50 mg PO bid; may increase daily dose to 200 mg if needed
CrCl 5-29 mL/min: Reduce maintenance dose by 50% (ie, administer 25 mg PO bid)
Pediatric
Not established
Coadministration of other serotonin reuptake inhibitors (eg, triptans, tramadol, SSRIs) and drugs that impair serotonin metabolism (eg, MAOIs) may cause serotonin syndrome; coadministration with drugs that affect platelet aggregation or coagulation may increase bleeding risk
Documented hypersensitivity; coadministration of MAOIs or MAOI administration within 2 wk; uncontrolled narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for worsening of depressive symptoms and suicide risk; increased risk of suicidal ideation, thinking, and behavior in children, adolescents, and young adults has been reported when taking antidepressants for major depressive disorder or other psychiatric disorders; not approved for use in pediatric patients; common adverse effects include nausea, headache, constipation, dizziness, insomnia, hot flashes, hyperhidrosis, vomiting, palpations, tachycardia, xerostomia, and hypertension; abrupt discontinuance may cause withdrawal symptoms (discontinue gradually)
May cause serotonin syndrome, particularly if coadministered with other serotonergic drugs (see Interactions); may elevate ALT and AST levels, and rare occurrence of fulminant hepatitis has been reported (risk increases with substantial alcohol ingestion or chronic liver failure); may increase risk of bleeding events; men with history of obstructive uropathies may have higher rate of genitourinary adverse effects
Anticonvulsants
These agents are used to manage pain and provide sedation in patients with neuropathic pain.
Clonazepam (Klonopin)
Effective drug to improve sleep. Should be titrated to lowest effective dose. When discontinuing, slowly taper over 7-14 d.
Adult
Starting dose: 0.125-0.25 mg (depending on the patient's history of drug intolerances or drug sensitivities) PO qd at 8 pm; increase to lowest effective dose
Pediatric
<18 years: Not recommended except in seizure disorders
>18 years: Administer as in adults
Alcohol, narcotics, barbiturates, nonbarbiturate hypnotics, and tricyclic antidepressants may potentiate effects
Documented hypersensitivity, severe liver disease and acute narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal insufficiency and chronic respiratory disease; can cause hypersalivation; caution patients (especially those receiving long-term high-dose treatment) to avoid abrupt discontinuation
Tiagabine (Gabitril)
Approved for treatment of seizures. In fibromyalgia, often used for effects on slow-wave sleep. Useful in improving sleep maintenance and decreasing whole-body pain in fibromyalgia.
Mechanism of action in antiseizure effect unknown; believed to be related to ability to enhance activity of GABA, major inhibitory neurotransmitter in CNS. May block GABA uptake into presynaptic neurons, making more GABA available for receptor binding on surfaces of postsynaptic cells; may prevent propagation of neural impulses that contribute to seizures by GABA-ergic action. Modification of concomitant AEDs not necessary unless clinically indicated.
Adult
4 mg PO divided bid or qid; increase by 4-8 mg/wk until clinical response or until 56 mg/d total; >56 mg/d PO not systematically evaluated in adequate well-controlled trials
Pediatric
<12 years: Not established
12-18 years: 4 mg PO qd; increase by 4 mg at beginning of wk 2; thereafter, may increase total daily dose by 4-8 mg/wk until clinical response or 32 mg/d;
>32 mg/d PO tolerated in small number of adolescents for relatively short duration
Cleared more rapidly in patients treated with carbamazepine, phenytoin, primidone, and phenobarbital than in patients not receiving these drugs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients receiving valproate monotherapy may require lower doses or a slower dose titration to clinical response; moderately severe to incapacitating generalized weakness reported in <1% of patients with epilepsy; weakness may resolve after reduced dose or discontinuation; should be withdrawn slowly to reduce potential for increased seizure frequency
Pregabalin (Lyrica)
Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha(2)delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, or fibromyalgia. Also indicated as adjunctive therapy in partial-onset seizures.
Adult
75 mg PO bid initially; increase to 150 mg PO bid within 1 wk based on efficacy and tolerability; may further increase dose to 225 mg bid if needed
Pediatric
Not established
May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min); angioedema has been reported during postmarketing surveillance
Gabapentin (Neurontin)
Membrane stabilizer, a structural analogue of inhibitory neurotransmitter GABA, which paradoxically is thought not to exert effect on GABA receptors. Appears to exert action via the alpha(2)delta-1 and alpha(2)delta-2 auxiliary subunits of voltage-gated calcium channels.
Used to manage pain and provide sedation in neuropathic pain.
Titration to effect can take place over several days to weeks.
Adult
Day 1: 300 mg PO qd
Day 2: 300 mg PO bid
Day 3: 300 mg PO tid and titrate prn; not to exceed 1200 mg PO qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe renal disease
Muscle Relaxant
These agents are helpful in the management of muscle spasm and rehabilitation measures.
Metaxalone (Skelaxin)
Treats muscle spasm and pain in fibromyalgia.
Adult
800 mg PO tid/qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity; known tendency for drug-induced hemolytic or other anemias; significantly impaired renal or hepatic function
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment
Tizanidine (Zanaflex)
Centrally acting muscle relaxant metabolized in the liver and excreted in urine and feces.
Adult
4-8 mg PO q8h prn; not to exceed 36 mg/d
Pediatric
Not established
May interact with alcohol (increase somnolence, stupor) and oral contraceptives (which decrease its clearance), and can cause increased hypotensive effects when administered concurrently with diuretics
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
Baclofen (Lioresal)
Muscle relaxant (central), presynaptic GABA-B receptor agonist that may induce hyperpolarization of afferent terminals and inhibit monosynaptic and polysynaptic reflexes at spinal level. Lessens flexor spasticity and hyperactive stretch reflexes of upper motor neuron origin. Eliminated through renal excretion. Effective in about 20% of patients. Appears to be of dramatic benefit in as many as 30% of children with dystonia, although benefit not always sustained. Well absorbed, with average oral bioavailability of 60% and mean elimination half-life of 12 h; steady state reached within 5 d with multiple dose administration; metabolism occurs in liver (P 450-dependent glucuronidation and hydroxylation); 6 major and a few minor metabolites produced.
Adult
5 mg PO tid for 3 d; 10 mg tid for 3 d; 15 mg tid for 3 d; 20 mg tid for 3 d; thereafter, additional increases may be necessary; not to exceed 80 mg/d PO divided qid
Pediatric
10-60 mg/d PO
Opiate analgesics, benzodiazepines, alcohol, tricyclic antidepressants, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase baclofen effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with history of autonomic dysreflexia and when spasticity is used to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication
Cyclobenzaprine (Flexeril)
Acts centrally and reduces motor activity of tonic somatic origins, influencing alpha and gamma motor neurons. Structurally related to tricyclic antidepressants.
Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established. Often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Adult
10 mg PO tid with a range of 20-40 mg/d in divided doses; not to exceed 60 mg/d
Pediatric
Not established
Coadministration with MAOIs and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine
Documented hypersensitivity; have taken MAOIs within the last 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in angle-closure glaucoma and urinary hesitance; may cause drowsiness, dizziness, and xerostomia
Nonbenzodiazepine Hypnotics
These medications are indicated for insomnia.
Zolpidem (Ambien, Ambien CR)
Indicated for insomnia. Structurally dissimilar to benzodiazepines but similar in activity, with the exception of having reduced effects on skeletal muscle and seizure threshold.
Agents of varying durations of action are used frequently for anxiety and panic and as sleep aids (poor sleep is nearly universal in fibromyalgia).
Adult
Starting dose: 10 mg PO qhs
Elderly dose: 5 mg PO qhs
Should be taken on a relatively empty stomach immediately before going to sleep
Pediatric
Not established
Increases toxicity of alcohol and CNS depressants; zolpidem's effect on insomnia may be delayed if taken with food or shortly after a meal
Documented hypersensitivity; lactation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor elderly for impaired cognitive or motor performance; extended-release dosage form must be swallowed whole (do not divide, chew, or crush)
Eszopiclone (Lunesta)
Nonbenzodiazepine hypnotic pyrrolopyrazine derivative of the cyclopyrrolone class. The precise mechanism of action is unknown but believed to interact with GABA receptor at binding domains close to or allosterically coupled with benzodiazepine receptors. Indicated for insomnia to decrease sleep latency and improve sleep maintenance. Short half-life of 6 h. Higher doses (ie, 2 mg for elderly and 3 mg for nonelderly adults) are more effective for sleep maintenance, whereas lower doses (ie, 1 mg for elderly and 2 mg for nonelderly adults) are suitable for difficulty in falling asleep.
Adult
Nonelderly adults: 2 mg PO hs; may increase to 3 mg PO hs prn
Elderly: 1 mg PO hs initially; not to exceed 2 mg PO hs
Severe hepatic impairment: Do not exceed 2 mg PO hs
Pediatric
<18 years: Not established
CYP3A4 and CYP2E1 substrate; potent CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin, nefazodone, ritonavir, nelfinavir) increases AUC, Cmax, and t1/2 and therefore potential toxicity (decrease dose); potent CYP3A4 inducers (eg, rifampicin) increases clearance; coadministration with alcohol or other CNS depressants may increase effect and toxicity (decrease dose); coadministration with olanzapine may decrease DSST scores; sleep onset may be delayed if taken with or immediately after a high-fat or heavy meal
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause dysgeusia, headache, or coldlike symptoms; rare adverse effects associated with hypnotics include short-term amnesia, confusion, agitation, hallucinations, worsened depression, or suicidal thoughts; high doses (ie, 6-12 mg) produce euphoric effects similar to those of diazepam 20 mg; anxiety, abnormal dreams, nausea, and upset stomach may occur within 48 h after discontinuing; alertness may be affected the following day, use caution operating machinery or driving a car
More on Fibromyalgia |
| Overview: Fibromyalgia |
| Differential Diagnoses & Workup: Fibromyalgia |
 Treatment & Medication: Fibromyalgia |
| Follow-up: Fibromyalgia |
| References |
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Further Reading
Keywords
fibromyalgia, myofascial pain, fibromyalgia symptoms, fibromyalgia pain, treatment fibromyalgia, symptoms of fibromyalgia, fibromyalgia syndrome, chronic fibromyalgia, fibromyalgia fatigue, interstitial myofibrositis, muscular hardening, muscular rheumatism, musculorheumatism, myofibrositis, myogelosis, myositism, nodular rheumatism, nonarticular rheumatism, rheumatic muscle callus, rheumatic muscle hardening, rheumatic myalgia, rheumatic pain modulation disorder, tension myalgia, fibromyositis, fibrositis, idiopathic myalgia
