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Dr. Podell Fibromyaltia Treatments—This is the “A List” of Fibromyalgia Medicines with the strongest support from double-blind studies:

Lyrica (pregabalin) is an anti-seizure drug that affects calcium channels. Pain improves by 50% for about one third of those who take it. Pain improves about 30% among half of patients.. Side effects can be a problem, with a fair incidence of increased fatigue, fluid retention, tremors, dizziness and weight gain. Neurontin (gabapentin), a similar drug, probably also works but with similar side effects.

Elavil (amitriptyline), a tricyclic antidepressant, acts to increase serotonin and norepinephrine brain neurotransmitters. As a fibromyalgia treatment Elavi is used, at much lower doses, than we use for depression. Elavil helps fibromyalgia in up to 50% of patients. Elavil can cause dry mouth, rapid heart rate and weight gain. Fibromyalgia doctors also recommend two medical cousins of Elavil-- Pamelor (nortriptyline) and Flexeril (cyclobenzaprine). Often these are better tolerated than Elavil itself.

Cymbalta (duloxetine) is an NSRI—a norepinephrine and serotonin reuptake inhibitor. It is FDA approved for depression and for the treatment of diabetic nerve pain. Cymbalta is effective for fibromyalgia whether or not the fibromyalgia patient is also depressed. Cymbalta’s mechanism of action is similar to that of Effexor. But, in contrast to Cymbalta, Effexor—though a very good antidepressant-- has not proved effective for fibromyalgia. Namenda (memantine), another drug of this class is not yet on the market in the U.S.

Xyrem (Sodium Oxybate) is approved by the FDA as a treatment for narcolepsy. However, three double blind studies show benefit for fibromyalgia pain and quality of sleep. Xyrem is the FDA approved form of GHB. On “the street” GHB has been abused as a date-rape drug. Prescription Xyrem has not been abused. Xyrem can give wonderful relief among a modest proportion of patients. However, Xyrem often has side-effects. Click here for Information About GHB and Fibromyalgia.

Mirapex (pramipexole) has been approved by the FDA to treat Parkinson’s Disease. However, one very good double blind study shows major benefit for fibromyalgia pain. Mirapex is also very good for a particular disorder of sleep, periodic leg movement disorder (PLMD), also known as Restless Legs Syndrome. Fibromyalgia Treatment for Mirapex should start at a very low dose. We slowly increase the dosing over a period of several months.

Ultram (tramadol) is a safer, less addictive cousin of the codeine group of opioid pain medicines. It can be taken on an as needed basis or around the clock. Fibromyalgia doctors often dose Ultraum at bed time and again if you wake during the night. Improving pain control at night often improves sleep.

Prozac - like SSRI anti-depressant drugs are usually not very useful for fibromyalgia pain; but they can be very useful for coexisting depression and/or anxiety. Non-steroidal anti-inflammatories such as aspirin, Ibuprofen, and Celebrex are less effective for FMS than they are for inflammatory conditions such as osteoarathritis and rheumatoid arthritis. Prednisone/Medrol/Cortisone is usually not useful for fibromyalgia. If corticosteroids help a lot, consider the possibility of a different illness e.g. polymyalgia rheumatica or temporal arteritis.

Well-Proved Natural Fibromyalgia Treatments:

Fibromyalgia doctors also recommend two very simple but powerful natural therapies. Both have multiple controlled studies showing benefit for treatment of fibromyalgia.

1) an appropriate program of slowly increasing exercise. But, this must be done carefully. Not too little and also not too much. We call this the “Goldilocks method”—do it “just right”.

2) CBT or Cognitive Behavioral Therapy is a specialized form of practical psychology that emphasizes day-to-day coping skills rather than “in depth” psychology. This is called cognitive behavioral therapy (CBT). Edwina (Wendy) King, PhD, APRN, our chief of behavioral medicine teaches basic and advanced relaxation skills and also reviews cognitive “reframing techniques”. David Burns, M.D. has very good books on CBT under titles such as Feeling Good and also The Feeling Good Workbook.

Fibromyalgia physicians agree: No fibromyalgia treatment plan is complete without attention to proper exercise re-conditioning and also to cognitive behavioral and stress reduction healing. Physical Therapy is also often very helpful. This can true even if the physical therapist is not specially trained in the special issues of posture and muscle trigger points that are very important in fibromyalgia. However, these approaches must be slow and gentle, or else flare-ups can occur. Physical therapists (or massage therapists) with special interest in Fibromyalgia often do better. We have been very pleased with the work of Carol Cote, P.T. and her associates in Morristown and Hackettstown, NJ. (tel: 908 852 7575.) We discuss both exercise and psychological adjuncts below in the section Functional Medicine Applications.

Dr. Podell’s Fibromyalgia Treatment “B List”: Innovative Medicines Whhich Fibromyalgia Doctors Believe Can Be Helpful But Which Lack Good Double Blind Studies

Each of the following innovative treatments help perhaps a proportion of people with moderate or severe FMS. The degree of benefit varies from mild to major.

These natural supplements might be useful: Magnesium, Malic Acid, 5 Hydroxy tryptophan. Acupuncture and frequency specific electrical stimulation might be useful for some. Low Vitamin D can bring out fibromyalgia. Be sure your doctor checks your blood level of 25 hydroxy vitamin D, and gets you up to a proper level.

Natural Thyroid Treatments: All physicins agree that persons who have low thyroid are more vulnerable to fibromyalgia. An “alternative medicine” minority believe that low thyroid can be a factor even if the thyroid blood tests are completely normal. There is some evidence to support this, but it is not completely proved. For appropriate persons we will often consider adding natural thyroid hormone.

See our thyroid section below for a fuller discussion.

Lyme disease is also a cause of fibromyalgia. Many people who have Lyme wind up with residual fibromyalgia. All agree that this is so. What remains controversial is whether such fibromyalgia-like “post-lyme” syndrome are caused by on-going Lyme infection that requires further antibiotic treatment. Most “main stream” experts believe that post Lyme fibromyalgia and other symptoms result from damage done by the original Lyme infection and do not have current infection. They do not believe that long term antibiotics will help. Certain alternative physicians dissent, and vigorously.

Dr. Podell’s opinion. Chronic active Lyme disease cases due occur, and, some respond very well to antibioitics. However, in the majority of cases antibiotics do not help. The key issue is deciding who should attempt antibiotics and who should not.

B-List Medications:

Zofran (odansetron) is a medicine usually used to treat the symptom of nausea caused by cancer chemotherapy. Zofran might also block the release of substance P, a pro-inflammatory neural hormone. Zofran is very expensive--if you don’t have a prescription plan. Constipation can be a major, even a dangerous problem. This must be watched carefully.

Zanaflex (tizanidine) is usually used to treat muscle spasticity in multiple sclerosis. Zanaflex modulates pain through certain sympathetic nervous system receptors. Zanaflex can be sedating and lower blood pressure. However, most people tolerate it. (Zanaflex is also fairly good for menopausal hot flashes.)

Baclofen also treats muscle spasticitity in multiple sclerosis. Baclofen stimulates GABA. Baclofen is usually well-tolerated. But sedation can be a problem.

Ketamine is an intravenous anesthetic that also blocks NMDA receptors. NMDA receptors play a major role in the central nervous system’s pain pathways. Oral Ketamine reduced FMS pain for about half the people . Unfortunately, Ketamine is also a potentially toxic drug. It’s abused on “the street” under the name of “Special K.” Ketamine is relatively safe and often useful as a topical salve. A compounding pharmacist can provide this. The anesthetic Lidocaine, given intravenously, is also effective, but, as an IV, is too toxic for office use. Lidocaine/Lidoderm patches, in contrast, are often useful for local areas of pain, and are very safe.

Folinic Acid (Leucovorin Calcium). Folinic Acid is a form of folic acid, that has been approved for use as a prescription drug. Recently a German research team reported a high degree benefit using Folinic Acid for Chronic Fatigue Syndrome. If that result can be confirmed, we might expect help for Fibromyalgia as well.

Other possibly useful medicines for Fibromyalgia Symptoms include: Dextromethorpphan, Amantadine, Memantine, Ritalin, Provigil, Seroquel, Zyprexa, Effexor, Deprenyl, Mestinon and low-dose Naltrexone and Guaifenesin.

Guaifenesin is a safe, mucus thinning agent found in Humibid, Entex and other medicines for respiratory infections. Dr. R. Paul St. Amand claims wonderful results using Guiafenesin to treat FMS. (What Your Doctor May Not Tell You About Fibromyalgia, Warner Books, 1999.) We have been skeptical, but recent testimonials are leading us to take a second look. For information on Guaifenesin and Fibromyalgia please see www.guiadoc.com.