Fibro

Question 1

Amitriptyline

Answer 1

Elavil

TCA

10-50mg/daily

Historically considered 1st line/gold standard

Serotonin and NE reuptake inhibitor

Limiting factors –> SE profile
Sedation, constipation and weight gain

Question 2

Fluoxetine

Answer 2

Prozac

20-80mg PO hs –> some efficacy

Decrease in “fibro-fog”, sleep and fatigue

Question 3

Duloxetine

Answer 3

(Cymbalta)
SNRI

• FDA Approved for FM
• Also has weak dopamine reuptake inhibition
• ↓ in pain severity and also trigger point assessment seen in clinical trials
• 60-120mg/day- start at 30mg and titrate dose up

ADR profile limiting- dry mouth, nausea, constipation
Dizziness- Tapering dose↑ tolerability

Question 4

Venlafaxine

Answer 4

(Effexor)
Inhibits serotonin, NE & DA (small degree)
*75mg/day –> Small trials –> some efficacy
*Large trials –> no difference from placebo

Question 5

Bupropion

Answer 5

(Wellbutrin)
Affects on NE and DA
Has not been studied in FM

Question 6

Milnacipran

Answer 6

(Savella)
NSRI

*FDA approved for FM
*NE and some 5-HT effect
*Showed efficacy in pain
—Also sleep, fatigue and cognitive disturbances
*Titration pack- 12.5mg starting dose
—Titrate up to 50mg twice/daily (max 200mg/day)
Limited by SE profile:
Nausea, HA, constipation, dizziness, insomnia, hot flush, hyperhidrosis, palpitations, ↑HR, dry mouth, HTN

Question 7

Cyclobenzaprine

Answer 7

(Flexeril)
muscle relaxant

Similar structurally to amitriptyline
Shown in studies to ↓pain and improve delta sleep
Doses of 10-40mg at bedtime
Limited by SE profile:
EXTREME drowsiness, dizziness, dry mouth
Counsel patient to take 1-2 hours prior to bedtime to ↓residual morning drowsiness

Question 8

Pregabalin

Answer 8

(Lyrica)
Neuron-specific Calcium Channel Blockers

↓the release of glutamate, NE, and Substance P

1st approved drug for FM in US
75mg bid titrated up to 450mg/day
↓ pain, fatigue and improved sleep quality
SE Profile:
Angioedema, weight gain, peripheral edema, vision changes

Question 9

Gabapentin

Answer 9

(Neurontin)
Neuron-specific Calcium Channel Blockers

↓the release of glutamate, NE, and Substance P

300mg hs titrated to 24oomg/day
↓ pain, improved sleep quality, vitality
Advantages over pregabalin:
More experience, lower cost, less peripheral edema, no risk of angioedema

Question 10

Pramipexole

Answer 10

(Mirapex)
Dopamine Agonists

0.25-4.5mg/day dosing
↓pain and fatigue and ↑ overall function
SE profile:
Sleep attacks and orthostatic HoTN –> not seen in this study
40% of patients (in this study) –> 5-25 lbs. weight loss