Medication Summary
Pharmacologic treatment of juvenile primary fibromyalgia syndrome (JPFS) is inferred from what has been studied and used in adult fibromyalgia. Typical medication regimens for pediatric fibromyalgia syndrome (FMS) primarily include skeletal muscle relaxants, low-dose tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). Some evidence reports that pain and symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with antidepressants and nonaddictive analgesics is effective.
Duloxetine (Cymbalta) was approved by the US Food and Drug Administration (FDA) in April 2020 for fibromyalgia in adolescents aged 13-17 years. [22]
Antidepressants
Class Summary
Antidepressant agents help decrease pain intensity and improve sleep quality. They counteract the hyperarousal mechanism in FMS and promote deeper sleep in children and adolescents. Some older, sedating medications are administered at bedtime or 1-2 hours before bedtime. SSRIs have been found useful for treating chronic pain states in adults.
Duloxetine (Cymbalta)
Duloxetine is a potent inhibitor of neuronal serotonin and norepinephrine reuptake. It is indicated for fibromyalgia in adults and adolescents aged 13-17 y.
Amitriptyline
Amitriptyline is used for analgesia for certain chronic and neuropathic pain conditions.
Imipramine (Tofranil)
These agents have been suggested to act by inhibiting reuptake of noradrenaline at synapses in central descending pain modulating pathways located in the brainstem and spinal cord.
Doxepin (Silenor)
Doxepin increases the concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by the presynaptic neuronal membrane. It inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Nortriptyline (Pamelor)
Nortriptyline has demonstrated effectiveness in the treatment of chronic pain.
Desipramine (Norpramin)
This is the original TCA used for depression. These agents have been suggested to act by inhibiting reuptake of noradrenaline at synapses in central descending pain modulating pathways located in the brainstem and spinal cord.
Skeletal Muscle Relaxants
Class Summary
Skeletal muscle relaxants may act centrally by a selective action on the central nervous system (CNS) and are principally used for relieving painful muscle spasms or spasticity that occurs in musculoskeletal and neuromuscular disorders. Their mechanism of action may be due, in part, to their CNS-depressant activity.
Cyclobenzaprine (Flexeril)
Cyclobenzaprine helps decrease the hyperarousal mechanisms in FMS and, in turn, helps the child sleep better. It is structurally related to the tricyclic antidepressants and exhibits similar pharmacologic effects. It primarily acts on the CNS at the brainstem level.
Nonsteroidal Anti-Inflammatory Drugs and Miscellaneous Analgesics
Class Summary
NSAIDs and miscellaneous analgesics are used for their anti-inflammatory, analgesic, and antipyretic effects. They are useful for the relief of mild-to-moderate pain.
Ibuprofen (Advil, Motrin)
Ibuprofen may help achieve analgesia when used in combination with skeletal muscle relaxants or tricyclic antidepressants. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses greater than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Naproxen (Aleve, Anaprox, Naprosyn)
Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis. NSAIDs decrease intraglomerular pressure and decrease proteinuria.
Acetaminophen (Tylenol, FeverAll, Tempra)
Acetaminophen is the drug of choice for pain in patients with documented hypersensitivity to aspirin or NSAIDs, patients with upper gastrointestinal disease, or those who are taking oral anticoagulants.
-
Illustration of 9 paired tender points identified in the 1990 statement of the American College of Rheumatology on fibromyalgia. They are as follows: (a) insertion of nuchal muscles into occiput, (b) upper border of trapezius, (c) muscle attachments to upper medial border of scapula, (d) anterior aspects of the C5–C7 intertransverse spaces, (e) second rib space 3 cm lateral to the sternal border, (f) muscle attachments to lateral epicondyle 2 cm below bony prominence, (g) upper outer quadrant of gluteal muscles, (h) muscle attachments just posterior to greater trochanter, and (i) medial fat pad of knee proximal to joint line.
