Prescribed Medications for Fibromyalgia

Prescribed Medications for Fibromyalgia: By Mark Pellegrino, M.D.

By Mark J. Pellegrino, M.D.

Mark J. Pellegrino, M.D., is Board Certified in Physical Medicine and Rehabilitation and Electrodiagnostic Medicine, and is one of the nation’s leading experts on fibromyalgia. Dr. Pellegrino is the author of numerous books and articles on Fibromyalgia, and despite having fibromyalgia, he maintains an active medical practice with over 10,000 patients cared for. He was recently named in “Best Doctors in America.” The following article is an excerpt from a chapter of "Inside Fibromyalgia by Mark Pellegrino, M.D."

Pain relief, improved sleep, and improved mood are examples of goals that prescription medicines can help you reach. As a group, those of us with fibromyalgia do not tolerate medicines well. We are very sensitive to medications and often experience side effects such as nausea, drowsiness, or lightheadedness. One person may tolerate a particular medicine, but the next person will get sick on it. Prescribed medicines can provide great benefits to many, however. Categories of drugs used in the treatment of fibromyalgia can include:

1) Analgesics

2) Anti-inflammatory medicines

3) Antidepressant medicines (tricyclics and selective serotonin reuptake inhibitors)

4) Muscle relaxants

5) Sleep modifiers

6) Anti-anxiety medicines

7) Other medicines used to treat chronic pain

1) Analgesics: Analgesics are pain killers and can include over-the-counter medicines such as aspirin and acetaminophen, or prescription-strength pain pills like narcotics (opiates), codeine, Vicodin, Darvocet, Oxycontin and Percocet. Ultram is a pain reliever that differs from narcotics in its action on the central nervous system. These medications do not alter the fibromyalgia, but they can help take the edge off of pain. Narcotic medications have potential for adverse side effects including drowsiness, difficulty with concentrating, and addiction, so they should be used carefully.

Many people with fibromyalgia are sensitive to codeine medicines, which can cause nausea or an allergic reaction. Ultram can cause allergic reactions in people sensitive to codeine, and a small number of people taking Ultram have seizures. As a pain specialist, I will frequently prescribe analgesics, including narcotics, for patients experiencing severe pain.

2) Anti-Inflammatory Medicines: Anti-inflammatory medicines include aspirin, nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen, Naprosyn, Lodine, Daypro, and the newer Cox-II inhibitors, and corticosteroids such as prednisone or dexmethasone. These medications are both anti-inflammatory and analgesic. Some of these medicines, such as ibuprofen, are available both over the counter and by prescription. Because fibromyalgia is not a true inflammation, these drugs may be less effective in reducing pain. However, these drugs can be helpful in reducing pain that flares up with excessive physical activity, tendonitis, or bursitis, and should be used only as needed. If the NSAIDs are helpful for overall fibromyalgia pain, they can be continued on a regular basis as long as there are no major side effects.

The major side effect of the anti-inflammatories is bleeding from gastrointestinal ulcers. This problem is more common the longer the medicine is taken. However, a new medication class is available, Cox-II inhibitors, which include Celebrex (Searle Pharmaceuticals), and Vioxx (Merck). This new form of NSAID selectively blocks only the Cox-II enzymes, which control the production of chemicals that cause inflammation and pain (prostaglandins). Good prostaglandins that help the stomach lining, kidneys, and platelets are formed by the Cox-I enzyme system and are not affected by the Cox-II inhibitors, thus avoiding gastrointestinal bleeding. I prescribe various types of anti-inflammatories on a regular basis. To avoid risk of bleeding or other side effects, patients must not take over the counter anti-inflammatory medicines if they are taking them by prescription.

3) Antidepressant Medicines: The antidepressant medicines include tricyclics (for example, amitriptyline, nortriptyline, doxepin, and trazodone), and selective serotonin reuptake inhibitors (Prozac, Zoloft, Paxil, Effexor, Serzone, and Celexa). These medicines can treat pain and alter sleep and mood disturbances seen in fibromyalgia. The tricyclic medicines are effective, but frequent side effects include dry mouth and drowsiness. Sleep disturbances can be reduced by using low doses. Carefully controlled studies have shown that low doses of tricyclic antidepressants can benefit fibromyalgia patients (Karette et al, 1986, Goldenberg et al, 1986).

Because of the extreme sedation and morning hangover effect common with amitriptyline, I’ve found that nortriptyline or trazodone has fewer side effects but gives the same benefit. Even though the sedation side effect of the tricyclic medicine may have worn off by morning, the other benefits of the drugs (decreased pain, muscle relaxation, and improved mood) can continue throughout the day. Because the tricyclic can provide more than one beneficial effect, I think these medicines are handy in fibromyalgia treatment.

The selective reuptake inhibitors work well in treating depression. They also block the breakdown of serotonin, the brain hormone that is low in persons with fibromyalgia and depression. Serotonin is important in the brain’s regulation of pain and sleep. By selectively inhibiting the breakdown of serotonin, these medicines increase the serotonin concentration in the body and its beneficial side effects. These medicines have fewer side effects than the tricyclics, although Zoloft and Paxil can cause sexual dysfunction. Some of the newer medicines, Effexor and Serzone, for example, do not inhibit sexual function. Using a combination of a serotonin reuptake inhibitor during the day and a tricyclic at nighttime can be an effective combination medicinal approach (Goldenberg, 1996).

4) Muscle Relaxants: Muscle relaxants can decrease pain in people with fibromyalgia. Medicines in this family include Flexeril, Soma, Skelaxin, and Robaxin. The most common side effect is drowsiness, although Soma and Skelaxin cause less of it. I have found that muscle relaxants do not really decrease muscle spasms or truly “relax” muscles, because the painful area still has palpable spasms. Rather, the medicine appears to help by a central neurologic mechanism that reduces muscle pain. If drowsiness is a side effect, this medicine should only be taken in the evening so it doesn’t interfere with driving or concentration. Flexeril is a popular medicine for evening. Although it is a muscle relaxant, it is very similar to amitriptyline in structure and effect, hence the benefits reported.

Medicines in the antispasticity category can be used to treat muscle spasms. Two of these medicines, Zanaflex and Baclofen, have been shown to help reduce back muscle spasms and pain. Antispasticity medicines are primarily intended for people who have neurologic conditions causing involuntary muscle spasms (such as spinal cord injuries, multiple sclerosis, or strokes). However, they may have a role in patients with fibromyalgia who have numerous muscle spasms.

5) Sleep Modifiers: Various medicines including those already mentioned, can treat insomnia (analgesics, antidepressants, and muscle relaxants). True sleep modifiers include benzodiazepines like Restoril and the hypnotic non-benzodiazepines such as Ambien. The most common reported concern about using sleep modifiers, especially benzodiazepams, is the habit-forming potential. Ambien is reported to be less habit-forming but can cause rebound insomnia when it’s stopped. Sonata is a newer sleep modifier that is not habit forming and doesn’t cause rebound insomnia. Sometimes sleep modifiers are prescribed in short intervals only.

I have found that sleep modifiers improve deep sleep, and particularly improve the morning perception of a good night’s sleep. This improved sleep can carry over into a better day. Sleep modifiers are short-acting medicines, so they work during the night and are usually eliminated from the body by morning, hence the low chance of a morning hangover. Some people report nightmares with these medicines, but usually these medicines are “silent,” that is, one doesn’t realize any medicine was taken, other than knowing that sleep was better. I’ve devoted a chapter of Inside Fibromyalgia (Chapter 26) to review the sleep problem so many of us have.

6) Anti-Anxiety Medicines: Anxiety is a common problem in fibromyalgia and contributes to pain, muscle tension, and irritability. It can make depression and insomnia worse. Various medicines including antidepressants and muscle relaxants treat anxiety. Benzodiazepines such as Klonopin, Ativan, and Xanax, are commonly used medicines. These medicines also cause sedation and thus can improve sleep. Possible side effects include depression and decreased memory. Sometimes it is hard to determine whether symptoms are due to fibromyalgia or are side effects of medication.

I have found Klonopin to be a particularly useful medicine in the evening, especially when there are leg symptoms (pain, restless leg syndrome, jerking of the legs called myoclonus) that interfere with sleep. Low dose Klonopin therapy is one way to improve the balance of the inhibitory receptors (GABA) and the excitatory receptors (MMDA) in the central nervous system. Most fibromyalgia patients have too much activity in the excitatory receptors (MMDA receptors), and Klonopin can increase the pain inhibitors’ activity to achieve a more normal balance, improving sleep and reducing pain.

7) Other Medicines Used to Treat Chronic Pain: Other medicines can be used to treat pain. Some pain medicines were originally developed for a different purpose. For example, anti-seizure medicines known as neuroleptics (including Neurontin, Dilantin, Depakote, and Tegretol) were later found to be helpful in treating pain, particularly neuropathic pain. People with fibromyalgia who have a lot of burning or electric shock feelings in their hands and feet may improve from a trial of neuroleptic medicines.

Headaches are a common problem with fibromyalgia, and various headache medicines are available. In addition to the medicines described above, headache medicines include ergot alkaloids, sumatriptan, calcium channel blockers, and beta blockers.

Other conditions associated with fibromyalgia such as irritable bowel syndrome can cause severe cramping pain and may require separately prescribed medications. Medicines used to treat irritable bowel syndrome include Metamucil, Levsin, and Levbid.

In addition to the variety of medicines available for fibromyalgia treatment, a variety of doctor “strategies” are also available. Doctors who prescribe medicine will usually find, through trial, and error, an effective and favorite strategy. There is no single right way to prescribe medicines for fibromyalgia, and more than one strategy may work for difference people and different doctors. Over the years, I have discovered basic strategies that seem to work best for me when using prescription medicines.

Antibiotics can have a role in treating fibromyalgia. Dr. Garth Nicolson has isolated a microorganism, Mycoplasma fermentens, as a possible infectious cause of Gulf War Syndrome (remember, this may be a type of fibromyalgia). Some patients had less pain and fatigue after taking antibiotics (for example, doxycycline, Zithromax), presumably due to the eradication of the Mycoplasma. Antibiotics may also inhibit certain enzymes that cause inflammation (anti-inflammatory mechanisms) rather than by acting as an anti-infection mechanism. I have had some patients who improved after a course of antibiotics and many who did not, so I’m not convinced that these drugs are helpful for the long term. Antibiotic use increases one’s chance of getting a Candida yeast infection, which can increase fibromyalgia symptoms. Over time, we may identify a specific subgroup of fibromyalgia patients who have antibiotic-responsive symptoms.

As with prescribed oral medications, therapeutic injections [Trigger Point Injections] can be considered on an individual basis as part of a multi-disciplinary treatment approach. I use a combination of prescription medicines and injections along with other treatment approaches. We need a lot of weapons to go after this “enemy” of our state of well being!

Fibromyalgia Survival Strategies:

• Understand there is no magical pill that will get rid of all fibromyalgia symptoms.

• Experiment with your doctor to determine which medicines can help “control” your symptoms.

• Responsibly use analgesics and narcotics to take the edge off the pain. These medications will not relieve all your pain but may improve symptoms and comfort.

• Educate yourself about expectations of medication.

• Use the lowest effective dose of medicine; wean off whenever possible [and discontinue any medication that is not working].

• Be flexible with medications. Keep it simple.

This article is reprinted with permission from the author, excerpted from Chapter 13 (pp.95-102) of Inside Fibromyalgia by Mark Pellegrino, M.D., (ISBN 1-890018-36-8, $24.50, Anadem Publishing, Inc., Columbus, OH 43214). Copyright 2001 Anadem Publishing, Inc. Inside Fibromyalgia may be purchased from Barnes & Noble and B. Dalton bookstores, or directly from Anadem Publishing at (800) 633-0055. You may also order this book online at www.Anadem.com.