Fibromyalgia

Description

Medications

To date, there is no single FDA-approved drug therapy that addresses all the symptoms of FMS. Drug therapy consists of antidepressants and pain relievers and is aimed at improving sleep and mood and relieving pain. However, pregabalin (Pfizer Inc.), a drug under development for the treatment of neuropathic pain, including fibromyalgia, is expected to receive FDA approval in 2004. Large-scale studies have suggested that pregabalin prevents pain symptoms and improves sleep disturbances in patients with fibromyalgia. It's believed that pregabalin slows the release of brain chemicals that may cause chronic pain.

Any ongoing drug regimen should be administered in combination with physical and cognitive behavioral therapies.

Targeting Pressure Points and Stretching Techniques

Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular program. Stretching technique used for muscle relaxation and pain reduction in fibromyalgia, however, are different and employ injections or cooling agents to inactivate the pressure points so that muscles can be stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One such technique is known as "spray and stretch." This method uses the following approach:

• The patient must be in a comfortable position.
• The partner presses on suspected tender points and the patient reports any pain.
• The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. (These chemicals are not anesthetics. They cool the blood vessels in the skin to inactivate the tender points. Anesthetic skin creams do not appear to be effective for this treatment.)
• The spray bottle is held upside-down about 12 to 18 inches from the targeted area. (The patient's face should be covered if the spray is being used near the head.)
• The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of an anesthetic such as lidocaine may be used for particularly painful tender points as an aid to stretching.

• The injection causes intense, transient pain in the trigger point. After the medication has taken effect, however, the ability to stretch the muscle is greatly enhanced.
• There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.
• In some cases, injections may be needed two or three times over six to eight weeks.

The benefits of this treatment may not be apparent immediately.

Antidepressants

Although antidepressants do not work for all fibromyalgia patients, a 2001 analysis of 10 studies reported that antidepressants can also help relieve pain, fatigue, and insomnia in about 25% of patients. None have been well researched for fibromyalgia, however. It should be noted that some patients report worse symptoms with antidepressants.

The two main classes of antidepressants used for fibromyalgia are the tricyclics and selective serotonin-reuptake inhibitors (SSRIs). Tricyclics are better at reducing pain and the SSRIs for relieving depression. Doses used specifically for fibromyalgia in nondepressed patients are often lower than for depression, so combinations may be an option. In fact, benefits may be strongest with combinations of the tricyclics and SSRIs.

Tricyclics. Tricyclics not only help relieve depression but they also have properties that reduce sleeplessness and muscle pain. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally only small doses are necessary for relief of fibromyalgia, so, although tricyclics have a number of side effects, they may occur less frequently in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Like all medications, tricyclics must be taken as directed; overdose can be life threatening.

Unfortunately, not all patients respond to tricyclics and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors (SSRIs). Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. In any case, they do not have any significant effect on tender points. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delayed or loss of orgasm and low sexual drive.

Dual Inhibitors. Dual inhibitors act directly on two neurotransmitters---norepinephrine and serotonin. They improve bladder capacity and may be helpful for people who also suffer from urinary incontinence. They also may help patients with chronic pain syndromes, such as fibromyalgia.

• Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. Some evidence suggests it may be helpful for some patients with fibromyalgia. As with the SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, of concern are recent reports of changes in blood pressure and heart conduction abnormalities, which may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
• Duloxetine (Cymbalta) also acts on both serotonin and norepinephrine and has been approved in the US for depression. In one study it also reduced muscle pain, which may have implications for fibromyalgia patients.
• Milnacipran (Ixel) is under investigation and is not yet approved in the US. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. A Phase III trial evaluating its use as a potential treatment for fibromyalgia is underway.

Other Antidepressants. Trazodone (Desyrel) is an antidepressant that might be specifically helpful for fibromyalgia sufferers. It is taken at bedtime and may be especially effective for promoting sleep.

Cyclobenzaprine

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It is related to the tricyclic antidepressants and has similar side effects, the most common being dry mouth, drowsiness, and dizziness.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) may improve sleep

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia.

• For relief of mild pain, acetaminophen (Tylenol) is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Such drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), and others.
• Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers that has been helpful for relieving painful areas in other disorders. It may have some value for fibromyalgia patients.
• Opioids, or narcotics, may be used for certain patients with moderate to severe pain or significant functional impairment who cannot find relief with other, less potent treatments. Some may be given combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids such as oxycodone (Roxicodone) or morphine sulfate (Duramorph) for patients who require ongoing relief. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids and periodically reevaluate the patient for continuing pain relief, side effects, and indications of dependence.
• Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has helped some people and was thought not to be addictive, although dependence and abuse have been reported. It can cause nausea. In one study, a tablet that combines tramadol with acetaminophen (Ultracet) significantly relieved pain without major adverse effects. Of note, however, nearly 20% of the patents stopped using it because of side effects. Another study reported that it was as effective for treating chronic pain as an acetaminophen/codeine combination.
• Intravenous lidocaine. The anesthetic lidocaine, which can offer pain relief when injected into tender muscle points during trigger point injections, may also offer benefits when it is infused into the veins. Preliminary results of a small British pilot study found that the infusions relieved pain and improved well-being in those who had not responded to other therapies. This approach has certain risks and more research is needed.

Anti-Seizure Agents (Anti-Convulsants)

Anti-seizure drugs, also called anti-epileptics or anticonvulsants, affect the neurotransmitter gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. Studies have shown that Gabapentin (Neurontin), an anti-seizure medication, affects pain transmission pathways and may relieve the pain associated with fibromyalgia. Phase I and II clinical trials are underway.

Other Investigative Drugs

Some treatments being tried for fibromyalgia are experimental and have potentially toxic side effects and interactions with other drugs. Patients should be sure to inform their physicians of any other drugs, including so-called natural remedies, that they are taking.

Botulinum. Botulinum toxin A (Botox) injections, a common wrinkle treatment, causes small muscles to relax. This approach is now being used with some success for treating disorders that cause over-excited muscle activity, including myofascial pain syndrome and migraine. Some researchers believe it may also help patients with fibromyalgia as well, although there is no evidence to date to support this and some early studies have been disappointing.

Tropisetron. Tropisetron (Navoban) is an agent used to reduce vomiting during chemotherapy. European studies are suggesting it may also help patients with fibromyalgia, including reducing pain, dizziness, and depression and improving sleep. Gastrointestinal upset and headaches were the most common side effects.

Growth Hormone. Some studies have suggested that growth hormones may benefit some patients with fibromyalgia who show evidence of deficiencies.

Muscle Stimulation

Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax then the process is stopped. Discomfort is minimal. Small studies are reporting some help in relieving fibromyalgia pain.