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May 2009

Treating Fibromyalgia
Antidepressants offer some relief for sufferers of fibromyalgia.

Donepezil in Schizophrenia?
A recent report suggests donepezil (Aricept) does not appear to benefit cognitive symptoms of schizophrenia.

Second-Generation Antipsychotics and the Risk of Cardiac Death
Second-generation antipsychotics produce about the same level of cardiac risks as first-generation agents.

Preventing Dementia
Higher levels of education, mentally challenging work, and moderate coffee consumption may protect against Alzheimer’s disease, but Ginkgo biloba does not.

In Brief
Mixed Results for Modafinil as an Adjunct in Schizophrenia; Memantine Not Efficacious as an Adjunct in Schizophrenia

Treating Fibromyalgia

May 2009

The American College of Rheumatology defines fibromyalgia syndrome (FMS) as chronic (lasting at least 3 months) widespread pain and tenderness at a minimum of 11 of 18 defined tender points.1 Among the many other physical and psychological symptoms of FMS are fatigue and nonrestorative sleep. FMS patients also frequently have migraine and tension headaches, irritable bowel syndrome, and mood and anxiety disorders.2 An estimated 0.5% to 5.8% of people in North America and Europe are believed to suffer from FMS.

Antidepressants are the most commonly employed and studied medications for this syndrome. Häuser and others conducted a meta-analysis, funded by the German government and other non-industry sources, of randomized controlled trials of antidepressants for FMS.1

The meta-analysis—of 18 trials, from 4 to 28 weeks in duration and involving 1427 participants—found strong evidence for the efficacy of antidepressants in reducing pain, sleep disturbances, and depressed mood and improving health-related quality of life. Unfortunately, all effect sizes were small. Antidepressants did not help with fatigue. Neither the few head-to-head antidepressant comparison studies nor the meta-analysis itself allow a definitive conclusion regarding the superiority of one class of antidepressants over another for FMS.

Tricyclic antidepressant (TCA) doses in these studies were between 12.5 and 50 mg/day. This is typical for pain treatment but below the usual antidepressant dosage, which is probably why TCAs reduced pain but not depression in this population. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) were used at the usual therapeutic dosages for treating depression, but only SNRIs appeared to reduce depression symptoms.

Three drugs are approved by the US Food and Drug Administration to treat FMS: pregabalin (Lyrica), duloxetine (Cymbalta), and as of January 2009, milnacipran (Savella). In a review of fibromyalgia, Stanford suggests that the sedating anticonvulsant pregabalin be considered first when pain and insomnia are major issues for a patient.2 Patients with prominent depression or who are sensitive to sedating agents might be considered for duloxetine or the newer SNRI milnacipran. The latter is approved as an antidepressant in many countries but not in the United States. Milnacipran has many of the same risks and side effects, including hypertension, as duloxetine. Other medications that have been tried in FMS patients include amitriptyline (Elavil and others), gabapentin (Neurontin and others), tramadol (Ultram and others), fluoxetine (Prozac and others), and venlafaxine (Effexor and others).2

There are few data on the long-term safety and efficacy of medications for FMS, yet patients are apt to be treated for years. Häuser et al suggest periodic reevaluation of the benefits and adverse effects in each patient.

Both Häuser et al and Stanford urge the setting of realistic goals for FMS patients. In FMS the goal is symptom reduction, not cure. In addition, Stanford recommends cognitive behavioral therapy—incorporating relaxation, coping skills, and cognitive training—as well as exercise and lifestyle changes.

FMS is a chronic disorder. New medications, combined with behavioral approaches, can offer some relief.

1Häuser W, Bernardy K, Üçeyler N, Sommer C: Treatment of fibromyalgia syndrome with antidepressants: A meta-analysis. JAMA 2009;301:198-209.

2Stanford SB: Fibromyalgia: Psychiatric drugs target CNS-linked symptoms. Current Psychiatry 2009;8:37-50.