Pharm - Fibromyalgia

Question 1

What is the drug of choice?

Answer 1

Tricyclic antidepressant - amitriptyline

Question 2

What are alternatives to amitriptyline?

Answer 2

• desipramine

- cyclobenzaprine

Question 3

What are the ADRs of amitriptyline?

Answer 3

• dry mouth
• constipation
• fluid retention
• weight gain
• grogginess
• difficulty concentrating

Question 4

What are the ADRs of cyclobenzaprine?

Answer 4

• anticholinergic effects
• CNS depression
• serotonin syndrome
• toxic potential like TCAs (cardiac effects)

Question 5

What symptoms are most responsive to duloxetine (Cymbalta)?

Answer 5

• severe fatigue (mental, not general)

- those that need depression treatment in addition to pain

Question 6

When is the best administration time for duloxetine?

Answer 6

In the morning at breakfast.

Question 7

What is the role of milnacipran in tx of fibromyalgia?

Answer 7

• alt to duloxetine in patients with severe fatigue with pain
• provides moderate levels of pain relief (30%) to 40% of patients receiving active drug

Question 8

What symptoms are most responsive to pregabalin?

Answer 8

More severe sleep disturbance in addition to pain

Question 9

What is the role of pregabalin in tx of fibromyalgia?

Answer 9

Indicated in patients unresponsive to or intolerant of amitriptyline (pregabalin preferred over gabapentin)

Question 10

What combination of meds should be used for patients unresponsive to monotherapy?

Answer 10

1. low dose SSRI/SNRI in the morning and TCA in the evening
2. low dose SNRI in the morning and low dose anticonvulsant in the evening
3. Acetaminophen, tramadol, NSAIDs used as adjunct for those without adequate response to these or with temporarily need for additional treatment during pain exacerbation

Question 11

When in therapy should tramadol be used?

Answer 11

Used alone or in combination in patients who require additional pain relief temporarily for disease exacerbation or for those that other therapies are inadequate in controlling pain.

Question 12

When in therapy should acetaminophen be used?

Answer 12

Used alone or in combination in patients who require additional pain relief temporarily for disease exacerbation or for those that other therapy is inadequate in controlling pain.

Question 13

Should you use NSAIDs and glucocorticoids long term?

Answer 13

NO***

• many trials have failed to show any effect from anti-inflammatory meds
• no evidence that tissue inflammation is present in patients with fibromyalgia
• glucocorticoids can have potential serious adverse effects when used chronically