Fibromyalgia Treatment

The aetiology of fibromyalgia remains unknown therefore effective causal treatment of this chronic pain syndrome is not available. Despite numerous therapeutic efforts all over the world the results are pretty unsatisfactory. Various and frequent symptoms experienced by fibromyalgia patients make them peregrinating from one to another medical specialist. Appropriate fibromyalgia treatment requires multidisciplinary approach and should cover i.a.:

  • Education
  • Psychotherapy
  • Pharmacotherapy
  • Dietetic management
  • Physiotherpay
  • Physical activity

Education

Patient’s education is essential in each chronic disease. And in fibromyalgia, which is a chronic pain syndrome education has particular importance. Fibromyalgia patients experiences constant pain and tiredness that discourages them from undertaking any life activity. They did not meet understanding from their relatives and friends usually. They did not get the help they need from their doctors quite often and over time they come up to the conviction about seriousness of their illness and approaching disability or imminent death. Understanding the nature of fibromyalgia and that there is no life risk or sudden disability threat is the corner stone of education in particular. It is important to draw attention on the relationship between stress factors and disease course. Taking that into consideration would help the patient in setting up personal plans and also therapeutic programme.

Our health depends in 50% on our life style this means it depends on our deliberate behaviours and decisions. Due to this fact so important is health education and forming appropriate pro-health behaviours. Everyone should be aware that the health maintenance is her/his duty and medical personnel supports to achieve that only. Constant contact with medical personnel during therapeutic course gives perfect occasion to widen the patient’s health knowledge. Applying the new pro-health behaviours and practices could be also continued beyond the therapeutic course.

Psychotherapy

Information about illness may cause in patient feeling of anxiety, anger, sorrow, or protest. However, patients learn to accept this illness and adopt to new circumstances over a time. The family, friends, our close people, and medical personnel have important role supporting the patient in her/his hard way.

The treatment is not only taking pills. Patients appropriate attitude is a key question. Stress can cause various changes in the body that may interfere with therapeutic process. Working together with patient should give her/him courage, hope, and believe in her or his own capability. Psychotherapy should make possible patient’s full engagement in the treatment process.

Different methods of psychotherapy are common fibromyalgia treatment procedures in the US in particular. Cognitive-behavioural therapy* (CBT) is one of the most popular therapeutic methods in fibromyalgia. CBT addresses some of the psychological components of the fibromyalgia. CBT increases patients' belief in their ability to manage their condition, and it helps them change pessimistic thoughts and negative feelings regarding symptoms like pain, fatigue, and sleep problems. The essence of psychotherapy are following steps:

  • Explanation psychological aspects of pain mechanism
  • Convincing patient that she/he is able to solve pain related problems
  • Forming an active life style
  • Endeavour to reduce the number of sick behaviours and increase the number pro-health behaviours
  • Decatastrophying pain

A specific form psychotherapeutic method is integration of fibromyalgia patients themselves and their families and close friends and volunteers into support groups. Members of support groups actively share negative and positive experiences, concerns and skills regarding how to cope in different situations and regarding their experience with various therapies, etc. A fibromyalgia patient that has certain training and skills is usually the leader of a support group in contrary to the formal therapeutic group that is managed by therapist.

Support groups, if conducted appropriately, have the potential to provide individuals with a number of benefits. First, they facilitate the exchange of information regarding a particular disease or condition between individuals who share that common illness. Next, support groups provide an outlet for the teaching and exchange of coping skills for relevant symptoms. Support groups also provide a non-judgmental and understanding environment in which individuals can talk to others about their common fears and feelings. In addition, support groups reinforce the belief that only another individual with the same condition or illness can truly understand how one feels. Support groups also provide patients with coping skills to overcome frightening symptoms. Finally, support groups allow others to enjoy the ability to help others help themselves.

The signs of support group activity could be find in internet and also in scientific meetings and conferences. The greatest number of supporting groups is in Germany and Nordic countries. One of the main advantages of the support group is the patient awareness that she or he is not alone and there are other people having similar problem. This is often big revelation and relief for the patient. The participation in support group, discussing personal questions publically might be an intimate issue and deserves discreetness and savoir-faire of all group members.


*Cognitive-behavioural therapy is a psycho-social intervention that is the most widely used evidence-based practice for improving mental health. Guided by empirical research, CBT focuses on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions (e.g. thoughts, beliefs, and attitudes), behaviors, and emotional regulation. It was originally designed to treat depression, and is now used for a number of mental health conditions.

One can read more on VeryWell health service → Cognitive Behavioral Therapy for Fibromyalgia

Physiotherapy

Physiotherapy is a field of contemporary clinical medicine that applies various forms of energy for therapy, rehabilitation and prophylaxis. It stems from the natural therapy originally that has been originated in historical methods that are scientifically proven and significantly developed in modern times. Physiotherapy could be an autonomous therapeutic method or can complement other therapies e.g. pharmacotherapy and surgery or may constitute a basis for rehabilitation and prophylaxis. In other words, physiotherapy constitutes therapy by nonspecific stimuli targeting recovery of state of equilibrium.

The methods applied in physiotherapy belong to so called natural healing/treatment methods due to reasons: they act on natural and physiological mechanisms of a homeostasis and they constitute natural element/component of an environment. There are different name of physiotherapy in literature, like physiatry, physicotherapy, physical medicine, or physical therapy. All these terms come from Greek language where φύσις = phusis means nature and θεραπεία = therapeīa means cure or healing.

Physiotherapy should be a constant element of fibromyalgia treatment plan. One of main tasks of physiotherapy is protection from muscles weakness and/or atrophy by applying its various types. The muscles are typically affected in fibromyalgia due to low physical activity and reluctance for physical exercise as a result of constant pain and tiredness. It is extremely important to tailor physiotherapy programme and methods for each fibromyalgia patient individually. The some type of physiotherapy could give relief to one patient and exacerbation to the other.

Among various types of physiotherapy one should list mostly following:

  • KINESIOTHERAPY (therapy by movement – it is the core element of physiotherapy. Motion (physical activity) has eminent impact on the whole body and constitutes basis for other forms of physiotherapy and rehabilitation).
  • PHYSICAL THERAPY (electrotherapy, magnetic field therapy, phototherapy, therapeutic ultrasound)
  • THERMOTHERAPY COLD and/or WARM (should be matched individually)
  • SPA TREATMENT and CLIMATE THERAPY i.a. with use of peat baths and natural healing waters (so called peloid therapy) and climate therapy, is based on use of the natural environment. Air-baths, sun-baths, sea-baths, inhalation of sea aerosols belong to that.

The optimal model of fibromyalgia treatment seems to be a combination of light physical exercises and whole body cryotherapy (WBC), which shows distinct pain reducing effect. However, this optimal model has to be set up together with an active use of fibromyalgia patients.

Kinesiotherapy

Kinesiotherapy or Kinesitherapy or kinesiatrics, from Greek κίνησις = kinēsis means movement and θεραπεία = therapeīa means cure or healing, is the therapeutic treatment of disease by passive and active muscular movements (as by massage) and of exercise. It is the core element of physiotherapy. Movement, as a therapeutic mean, has an impact on all body's organs and tissues as natural therapeutic stimuli.

The role of therapeutic movement and physical exercises was appreciated in ancient China, Egypt, Greece and India. Hypocrites, except of the famous "primum non nocere" said also that the medical knowledge rests on two pillars that are physical exercise and dietetics.

Kinesiotherapy (treatment by movement) is also described as rehabilitation by movement, medical training, therapeutic exercise, and as physiotherapy, recently.

The kinesiotherapy techniques comprise of passive forms of movement – passive kinesiotherapy and active forms of motion – active kinesiotherapy. The choice of an appropriate technique is based on functional status of a patient, location of disease process, illness or injury. The therapeutic exercises could be divided depending on their range of impact into limited range of movement – local kinesiotherapy, e.g. increase in knee joint movement and/or general kinesiotherapy – a general motion having impact on the patient general physical performance, improving circulatory system, respiratory system and also engaging musculoskeletal and nerve (kinetic) system.

Physical Therapy

Amoung various methods of physical therapy we can list the most common:

  • Hydrotherapy also called water cure, is a part of naturopathy that involves the use of water for pain relief and treatment. The term encompasses a broad range of approaches and therapeutic methods that take advantage of the physical properties of water, such as temperature and pressure, for therapeutic purposes, to stimulate blood circulation and treat the symptoms of certain diseases.

  • Thermotherapy it a treatment that uses termal energy. The energy can be delivered to the body (warm treatment) as well as it can be received (cold treatment). The particular type of cold treatment is cryotherapy. Cryotherapy is widely used to relieve muscle pain, sprains and swelling either via soft tissue damage or postoperative swelling. It can be a range of treatments from the very low technology application of ice packs or immersion in ice baths (generally known as cold therapy) to the use of cold chambers (whole body or partial body cryotherapy) and or face masks or body cuffs with controlled temperature, sometimes called hilotherm.

  • Therapeutic Ultrasoud is a modality that has been used by physiotherapists since the 1940s. Ultrasound is a method of stimulating the tissue beneath the skin's surface using very high frequency sound waves, between 800,000 Hz and 2,000,000 Hz, which cannot be heard by humans. It is applied using the head of an ultrasound probe that is placed in direct contact with your skin via a transmission coupling gel.

  • Electrotherapy is the use of electrical energy as a medical treatment. In medicine, the term electrotherapy can apply to a variety of treatments, including the use of electrical devices such as deep brain stimulators for neurological disease. The term has also been applied specifically to the use of electric current to speed wound healing. Additionally, the term "electrotherapy" or "electromagnetic therapy" has also been applied to a range of alternative medical devices and treatments.

  • Among various form of electrotherapy it is worth to mention TENS (Transcutaneous Electrical Nerve Stimulation) with low voltage current. This therapeutic method is based on gate control theory. TENS is done with a small, battery-powered machine about the size of a pocket radio. Usually, two electrodes are conected (wires that conduct electrical current) from the machine to skin. The electrodes are often placed on the area of pain or at a pressure point, creating a circuit of electrical impulses that travels along nerve fibers. When the current is delivered, some people experience less pain. This may be because the electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that block or "scramble" normal pain signals. Another theory is that the electrical stimulation of the nerves may help the body to produce natural painkillers called endorphins, which may block the perception of pain.

  • Magnetic Field Therapy uses different kinds of magnets on the body to help boost your overall health. It may also help treat certain conditions. There are several types, including: Static magnetic field therapy – in this, magnet touches skin somehow. You might wear a magnetic bracelet or other magnetized jewelry. It could be a bandage with a magnet in it, or you may wear a magnet as a shoe insole. You could also sleep on a special mattress pad with a magnet in it. Electrically charged magnetic therapy (electromagnetic therapy): The magnets you use here have an electric charge. Treatment with electromagnetic therapy usually comes through an electric pulse.

  • Therapuetic Massage it is defined as the mobilisation of soft tissue (such as muscle, fascia and body fluids) to restore normal systemic and biomechanical/functional use. It can be used to assist in the treatment of most musculo-skeletal and associated problems, and regular therapeutic massage results in improved circulatory, lymphatic and neurological functioning. There are many types of massage therapy, from classics like Swedish and deep tissue to more exotic styles like shiatsu. One can read more on VeryWell health service → Nine popular types of massage

It is very important to take into consideration the individual patient situation and preferences when deciding upon physiotherapeutic method. The physiotherapeutic method that gives very positive results in one patient may give adverse results to other, it may even aggravate symptoms.

Dietetic Treatment

Many doctors and therapists recommend tryptophan rich diet for people suffering from fibromyalgia. Results of studies evaluating effects of such diet are ambivalent and should be confirmed by decent clinical studies. One that would like to get familiar with this subject should go to bookmark ⇒ diet and fibromyalgia.

Dietary Supplements

Some dietary supplements (e.g. Myalgan) might be also helpful in dietetic management of fibromyalgia. Some studies from Poland, Norway and Sweden may indicate their beneficial effect and safety. Read more ⇒ about Myalgan

Among dietary supplements that may be used in fibromyalgia following are listed:

  • Vitamin D – new research finds achieving healthy vitamin D levels helps relieve symptoms of chronic widespread pain. Furthermore, several trials have concluded that vitamin D has an antidepressant effect.
  • Fish Oil – Omega 3 fatty acids act as precursors to chemicals that help reduce pain and inflammation. By contrast Omega 6 fatty acids can increase inflammation and create chronic pain.
  • S-Adenosyl l-Methionine (SAMe) – Jacobsen at al have found oral S-adenosylmethionine beneficial in primary fibromyalgia in double blind clinical evaluation. Scand J Rheumatol. 1991;20(4):294-302.
  • d-Ribose – it is a pentose simple sugar (monosaccharide with five carbon atoms), which after phosphorylation helps cells produce i.a. tryptophan. Teitelbaum and Johnson have found in a pilot study that d-ribose significantly reduces clinical symptoms in patients suffering from fibromyalgia and chronic fatigue syndrome. J Altern Complement Med. 2006 Nov;12(9):857-62.
  • Magnesiumsome studies suggest that topical application of magnesium may help in easing fibromyalgia symptoms, such as tender points. Some authors postulated that low magnesium levels in muscle cells may be a factor in fibromyalgia development.
  • Brown Seaweed Extract – 1,000 mg of brown seaweed extract daily can reduce joint pain and stiffness by 52%, according to a 2011 study from Australia’s Center of Health and Wellbeing, published in the journal Biologics.

There are also many other supplements having more or less documented positive effect in fibromyalgia. However, if you have doubts whether they will suit you it is important to consult your doctor before taking them.

Other Treatments

Immune System Support

It is believed that some dysfunction of immune mechanisms occurs in the background of majority of fibromyalgia cases. Two auto-antibodies anti-68/48 kD and anti-45 kD are taken into consideration as markers of the primary fibromyalgia and chronic fatigue syndrome. The rise of anti-polymer antibodies level has been found in fibromyalgia patients. Thirty percent of fibromyalgia patients has anti-nuclear antibodies (ANA), from which 75% shows mottled pattern. The studies have shown increased levels of IL-10, IL-8 and IL-6 and TNF-alpha as compared to health subjects. IL-8 promotes sympathetic pain and IL-6 indices tiredness, depression, hyperesthesia, and pain perception.

Breakthrough research at College of Medicine of University of Illinois at Chicago published recently should give more light into nature of fibromyalgia syndrome. This study has compared fibromyalgia patients and healthy subjects and revealed that certain dysfunction of immune system might be the underlying background of fibromyalgia. The identification of the immune path of fibromyalgia has been awarded with the prize for Outstanding Research in Clinical and Diagnostic Immunology by the American Association for Clinical Chemistry in 2012 and also brings hope for development of an objective diagnostic test for fibromyalgia.

It is worth to take into consideration immunomodulating preparations in fibromyalgia treatment. We recommend our Immulina Plus a modern immune-supplement that has positive impact on immune health.


*Sympathetic pain – pain related to muscle tension disorder after stroke and spastic paresis.
Interview with Dr. Bruce Gillis, CEO of the EpicGenetics Inc.: Fibromyalgia Diagnosis
Immunomodulation - is modulation (regulatory adjustment) of the immune system. It has natural and human-induced forms, and as part of immunotherapy, in which immune responses are induced, amplified, attenuated, or prevented according to therapeutic goals.

Alternative (Complemetary) Medicine / Non-conventional Medicine

Complementary medicine (CM) or integrative medicine (IM) is when alternative medicine is used together with functional medical treatment, in a belief that it improves the effect of treatments. However, significant drug interactions caused by alternative therapies may instead negatively influence treatment, making treatments less effective. Both terms refer to use of alternative medical treatments alongside conventional medicine, an example of which is use of acupuncture (sticking needles in the body to influence the flow of a supernatural energy), along with using science-based medicine, in the belief that the acupuncture increases the effectiveness or "complements" the science-based medicine.

Pharmacotherapy

The U.S. Food and Drug Administration (FDA) has approved three medicines for fibromyalgia therapy, recently. There are: pregabalinγ-amino-butyric acid (GABA) analogue used for epilepsy and neuropathic pain therapy and duloxetine and milnacipran both are serotonin and norepinephrine reuptake inhibitors (SNRIs) used in depression therapy. Readers may find a review of pharmacotherapy in fibromyalgia in → Update on Treatmment Guideline in Fibromyalgia Syndrome with Foccus on Pharmacology (pdf file 24 pages) by Sanam Kia and Emet Choy from Wales, UK and published in Biomedicines.2017,Jun;5(2):20.

Antiepileptic Drugs

Some antiepileptic drugs that were used for neuropathic pain* therapy might be also helpful. Carbamazepine and oxcarbazepine have been tried commonly. However, the number of side effects and modest effectiveness made their use limited. Some hope can give pregabalin – antiepileptic medicine used for peripheral neuropathic pain treatment. The mechanism of this drug remains unknown however, it seems it could influence inhibition of hyper-reactive neurons and could influence the neuromediators release transmitting signals from one neuron to another.


*Peripheral neuropathy is damage to or disease affecting nerves, which may impair sensation, movement, gland or organ function, or other aspects of health, depending on the type of nerve affected. Common causes include systemic diseases such as diabetes, hyperglycemia-induced glycation, vitamin deficiency, medication (e.g., chemotherapy), traumatic injury, including ischemia, radiation therapy, excessive alcohol consumption, immune system disease.

Pregabalin

The pregabalin usefulness in soothing fibromyalgia symptoms has been evaluated in couple of clinical studies. A multicenter, double-blind, randomized controlled trial (RCT) was conducted in 750 patients who were randomized to receive pregabalin 300, 450 or 600 mg per day or placebo for 14 weeks; significant improvement in pain and other functional measures was achieved in all the pregabalin groups as compared to the placebo group. A systematic review evaluating the efficacy of pregabalin found a benefit of pregabalin relative to placebo in pain reduction, improvement in sleep and quality of life measures (except for mood variables). A meta-analysis of 4 RCTs with more than 3,000 patients has shown that a 30% pain reduction was reported by 40% of patients receiving pregabalin versus 28% of those receiving placebo.


* R = randomized, CT = placebo controled trial

References: Häuser W, Bernardy K, Uçeyler N, Sommer C. Treatment of fibromyalgia syndrome with gabapentin and pregabalin - a meta-analysis of randomized controlled trials. Pain. 2009;145(1–2):69–81.

Serotonergic Drugs

The preparations that interact with serotonin system seem to be the most promising. The preparations blocking 5-HT2 and 5-HT3 receptors playing important role in pain sensation and sleep quality have been investigated. Reduction of symptom has been observed in 50% of patients. Because of low mood and depression observed in the course of fibromyalgia psychotropic drugs were commonly used. Amitriptyline has been used as a drug of choice initially. However, controlled clinical trials revealed efficacy in less than 30% of patients with fibromyalgia. The adverse effects that accompanied administration of amitriptyline and other tricyclic antidepressant (TCA) caused resignation of this antidepressants and draw attention to the second generation drugs having mainly receptor mode of action. The selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, and citalopram are in that group. However, effectiveness of these preparations in fibromyalgia therapy is ambivalent and they have not found wider clinical usage.

The third group of antidepressants characterized in both serotonin and norepinephrin reuptake inhibition raises better hopes. There were promising clinical results of mirtazapin administration. Mirtazapin acts as a noradrenergic and specific serotonergic antidepressant (NaSSA). Chemically, mirtazapine is a tetracyclic antidepressant (TeCA), with four interconnected rings of atoms. It also shows potent antihistamine effect.

Duloxetine

Duloxetine belongs to a class of medications called serotonin and norepinephrine reuptake inhibitors (SNRIs) and it also weekly inhibits dopamine reuptake. It is a medication mostly used for major depressive disorder, generalized anxiety disorder, fibromyalgia and neuropathic pain.

Duloxetine, sold under the brand name Cymbalta among others. The U.S. Food and Drug Administration (FDA) previously approved duloxetine for the treatment of depression, generalized anxiety disorder, and diabetic peripheral neuropathic pain. The agency approved Cymbalta for the management of fibromyalgia in adults in June 2008.

Sleeping disorders, concentration problems, chronic fatigue, low mood, lack of appetite are pretty common among people with chronic pain disease. These symptoms also belong to the common clinical picture of depression. Clinical research confirms that depression is frequent result of chronic pain diseases. The risk of depression is the higher the bigger (longer) is pain intensity.

Duloxetine has shown to be effective for both mood disorders and fibromyalgia sufferers. It is one of the more widely prescribed medications for fibromyalgia patients by healthcare practitioners. Duloxetine for fibromyalgia can minimize many of the symptoms of fibromyalgia, such as musculoskeletal pain, depression, anxiety, brain fog, and more.

While duloxetine can be beneficial to anyone suffering from fibromyalgia, it is important to be aware of potential side effects that may result from its use. These include just to mention the most common: vision changes, dizziness, drowsiness, fatigue, loss of appetite, dry mouth, increased sweating.


Epstein SA, Kay G, Clauw D, Heaton R, Klein D, Krupp L, Kuck J, Leslie V, Masur D, Wagner M, Waid R, Zisook S. Psychiatric disorders in patients with fibromyalgia. A multicenter investigation. Psychosom. 1999; 40: 57–63.

Milnacipran

Milnacipran is one of three medications currently approved by the Food and Drug Administration in the United States for the management of adult FMS patients. Milnacipran is a mixed norepinephrine (more) and serotonin (less) reuptake inhibitor thought to improve FMS symptoms by increasing neurotransmitter levels in descending central nervous system inhibitory pathways. Milnacipran has proven efficacy in managing global FMS symptoms and pain as well as improving symptoms of fatigue and cognitive dysfunction without affecting sleep. Due to its antidepressant activity, milnacipran can also be beneficial to FMS patients with coexisting depression. However, side effects can limit milnacipran tolerability in FMS patients due to its association with headache, nausea, tachycardia, hyper- and hypotension, and increased risk for bleeding and suicidality in at-risk patients. Tolerability can be maximized by starting at low dose and slowly up-titrating if needed. As with all medications used in FMS management, milnacipran works best when used as part of an individualized treatment regimen that includes resistance and aerobic exercise, patient education and behavioral therapies.


Vitton O, Gendreau M, Gendreau J, Kranzler J, Rao SG. A double-blind placebo-controlled trial of milnacipran in the treatment of fibromyalgia. Hum Psychopharmacol. 2004;19(Suppl 1):S27–S35.

One may be also interested in  → Management of Fibromyalgia Syndrome: Review of Evidence

Winfried Häuser at al. published a comparative review in Rheumatology, Volume 50, Issue 3, 1 March 2011, Pages 532–543,

Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran in fibromyalgia syndrome: a systematic review with meta-analysis

Results. Ten amitryptyline studies (612 patients), four duloxetine studies (1411 patients) and five milnacipran studies (4129 patients) met the inclusion criteria. The reported methodological quality of most amitryptyline trials was poor, that of duloxetine and milnacipran were high. The three drugs were superior to placebo except duloxetine for fatigue, milnacipran for sleep disturbance and amitryptyline for health-related quality of life. The significant effects of amitryptyline and duloxetine were small and those of milnacipran not substantial. In adjusted indirect comparisons, amitryptyline was superior to duloxetine and milnacipran in reduction of pain, sleep disturbances, fatigue and limitations of health-related quality of life. Duloxetine was superior to milnacipran in reducing pain, sleep disturbances and limitations of health-related quality of life. Milnacipran was superior to duloxetine in reducing fatigue. There were no significant differences in acceptability of the three drugs.

Painkillers and Non-Steroidal Anti-Inflammatory Drugs

Fibromyalgia pharmacotherapy is mainly focused on reduction of chronic widespread pain symptoms. Painkillers, muscle relaxants, NSAIDs, antidepressants are the drugs that are commonly used. The common painkillers and NSAIDs are hardly effective, what could be additional diagnostic argument. Fibromyalgia pain does not respond to painkillers neither too NSAIDs. Tramadol is the only drug that show certain beneficial effect for fibromyalgia symptoms mainly due to its activity to serotonin receptors (5-HT).

Clinical trials of NSAIDs did show up limited value of this group of drugs. However, muscle relaxants combined with painkillers could give some betterment in part of fibromyalgia patients.


NSAIDs = Non-Steroidal Anti-Inflammatory Drugs – are a drug class that reduce pain, decrease fever, prevent blood clots and, in higher doses, decrease inflammation. Side effects depend on the specific drug, but largely include an increased risk of gastrointestinal ulcers and bleeds, heart attack and kidney disease.

Tramadol

Tramadol, sold under the brand name Ultram among others in the UK, US, and Australia. It is an opioid pain medication used to treat moderate to severe pain.

It works by binding to the μ-opioid receptor and as a serotonin–norepinephrine reuptake inhibitor (SNRI). Tramadol is in the benzenoid class. In the body it is converted to desmetramadol, which is a more potent opioid. In this mmechanism it works like other antidepressants increasing serotonin and norepinephrine levels in centeral nervous system.

Common side effects include: constipation, itchiness and nausea. Serious side effects may include seizures, increased risk of serotonin syndrome, decreased alertness, and drug addiction.

Muscle Relaxants

Stiffness is one of the most common symptoms of fibromyalgia. It affects muscles and joint surrounding connective tissue and structures (ligaments, tendons, fascias, etc.).

Cyclobenzaprine is a drug used to relax muscles. Experts do not know exactly how this drug works to improve fibromyalgia. Cyclobenzaprine is recommended to treat the pain, stiffness, and sleep problems that occur with fibromyalgia. People with fibromyalgia who take cyclobenzaprine seem to notice an overall improvement in their symptoms. And they especially note improved sleep. The cyclobenzaprine effects may decrease over time.

Tofferi JK et al. made meta-analysis of five randomized, placebo-controlled cyclobenzaprine trials. Authors found pain reduction early, but there was no improvement in fatigue or tender points at any time. Cyclobenzaprine-treated patients were 3 times as likely to report overall improvement and to report moderate reductions in individual symptoms, particularly sleep. Arthritis Rheum. 2004 Feb 15;51(1):9-13.

New Drugs

Sodium Oxybate

Sodium oxybate is the sodium salt of γ-hydroxybutyric acid (GHBA). It is sold in the US under trade name Xyrem. The medicines providing hydroxybutyric acid salts are available on a special prescription only. The U.S. Food and Drug Administration (FDA) has approved sodium oxybate to treat cataplexy and excessive daytime sleepiness in patients with narcolepsy*, which is a potentially debilitating disease.

Several randomized, controlled trials demonstrated significantly improved fibromyalgia symptoms with sodium oxybate. As seen in narcolepsy trials, sodium oxybate improved sleep of fibromyalgia patients, increased slow-wave sleep duration as well as delta power, and reduced frequent night-time awakenings. Furthermore, fibromyalgia pain and fatigue was consistently reduced with nightly sodium oxybate over time. Commonly reported adverse events included headache, nausea, dizziness and somnolence. Despite its proven efficacy, sodium oxybate did not receive FDA approval for the management of fibromyalgia in 2010, mostly because of concerns about abuse.


*According to the National Institutes of Health, narcolepsy is a chronic brain disorder that involves poor control of sleep-wake cycles. People with narcolepsy experience periods of extreme daytime sleepiness and sudden, irresistible bouts of sleep that can strike at any time. These “sleep attacks” usually last a few seconds to several minutes.

Tricyclic Antidepressants

This an old group of antidepressant drugs, to which belong i.a. amitriptyline and cyclobenzaprine – with a new possible indication. Cyclic antidepressants block the absorption (reuptake) of the neurotransmitters serotonin (ser-o-TOE-nin) and norepinephrine (nor-ep-ih-NEF-rin), increasing the levels of these two neurotransmitters in the brain. Cyclic antidepressants also affect other chemical messengers, which can lead to a number of side effects. Exact action mechanism of tricyclic antidepressants is unknown. It is probably related to increase of synaptic transmission in adrenergic and serotonergic neurons in the brain due to decreased reuptake and reduced inactivation of epinephrine and serotonin in the endings of these neurons. This leads to the increase of these neurotransmitters in the intersynaptic space. The sedative effect of amitriptyline is probably related to its anti-histamine effect. The full therapeutic effect is observed after dozen or so days of administration. Amitriptyline shows also strong anticholinergic* effect both in CNS and peripheral autonomic nervous system.

Indications: for depression therapy, in situations where patients needs sedation, particularly. For chronic pain treatment i.a. neuropathic pain and tension headache (last indication not registered in Poland).


*An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. These agents inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The nerve fibers of the parasympathetic system are responsible for the involuntary movement of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, and many other parts of the body. Anticholinergics are divided into three categories in accordance with their specific targets in the central and peripheral nervous system: antimuscarinic agents, ganglionic blockers, and neuromuscular blockers

Dopamine Receptor Agonists

There is a theory (the ‘dopamine hypothesis of fibromyalgia’) that fibromyalgia syndrome is caused by problems with dopamine neurotransmission. Dopamine is involved in the perception of pain and in pain reduction, and pain is a key symptom in fibromyalgia syndrome. Dopamine also appears to be important in restless leg syndrome, which has symptoms of burning, itching or crawling sensations under the skin, resulting in an irresistible urge to move the legs, especially in the evening and night. Dopamine receptor agonist biperiden has been successfully used for restless leg syndrome treatment in some people with fibromyalgia syndrome. However, dopaminergic drugs are commonly used for the Parkinson's disease therapy.

Pramipexole

Pramipexole was developed by Boehringer Ingelheim, and is a D3 agonist used in the treatment of Parkinson's disease and restless-leg syndrome. In a study of patients with long-term and severe fibromyalgia syndrome, Pramipexole significantly reduced pain. Side effects included anxiety, which wore off as the trial went on, nausea and weight loss.

The European League Against Rheumatism (EULAR) recommends the use of pramipexole in the treatment of fibromyalgia syndrome, to reduce pain. This is an off-label use (used outside the indications that the drug is officially approved for), and the company does not appear to be developing pramipexole for fibromyalgia syndrome.

Cannabinoids

Cannabinoids show clear anti pain activity in different clinical conditions. The synthetic analogues like e.g. nabilone is usually used. However the data regarding use of cannabinoids in fibromyalgia are controversial or diverse. They are some studies confirming such activity and other that neglect such effect. Authors tried in this study to assess the efficacy, tolerability, and safety of cannabinoids for fibromyalgia symptoms in adults. The study is accessible → Cochrane Pain Palliative and Supportive Care Group.

Nabilone did not ease fibromyalgia symptoms (pain, sleeping disorder, chronic fatigue) significantly better as compared with placebo or amitriptyline. There were more adverse and undesired effects as compared with placebo and amitriptyline. However, there were no any serious side effects observed.

Authors conclude that they did not found any convincing, unbiased, high quality evidence suggesting that nabilone is of value in treating people with fibromyalgia. The tolerability of nabilone was low in people with fibromyalgia.

New Therapy?

Dr. Paul St. Amand, endocrinologist, that suffers from fibromialgia himself, as several of his family members, investigated guaifenesin effect on fibromyalgia course. Guaifenesin is etheric derivate of guaiacol an expectorant medication sold over the counter. Guaiacol is a precursor to various flavorants, such as eugenol and vanillin. The theoretical background is an assumption (not scientifically confirmed) that several fibromyalgia symptoms are related to low energy level in cells due to low ATP level in those cells. This low ATP cellular level is because accumulation of phosphates in tissues. Dr. Amand believes that guaifenesin would facilitate to remove excessive phosphates through kidneys thus reverse the process that, as he believes, lies in the background of fibromyalgia. He developed a maintenance system so called guaifenesin protocol for fibromyalgia, where alongside with administration of guaifenesin any forms of salicylates are eliminated.




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