Medication generic/trade

Clinical Pearl

Common dosage

FM usage

Alprazolam/Xanax

Extremely short half-life. May not suitable for sleep aid.

0.25-3 mg/day

Panic attacks

Amitriptyline/Elavil

Most tested agent in FM. Use supported by meta-analyses published recently in JAMA.

10-50 mg at hs in single dose

Mild Pain, sleep

Apo-zopliclone

Precursor of Lunesta. Only available by mail order through Canada

7.5 mg at hs

Sleep

Bupropion Hydrochloride/Wellbutrin*

May augment SSRI/SNRI

Slow release 150-300 mg SR bid or 300 XL qd

Fatigue, fibro fog

Carbidopa, Levodopa/Sinemet*

Inexpensive.

10/100-20/200, 1 tab hs

Restless leg syndrome

Carisporodol/Soma*

Use only at hs if causes daytime fatigue.

350 mg, 1-4 times per day

Muscle relaxation, pain

Clonazepam/Klonopin, Clonapam*

In one author’s opinion (KDJ), one of the best adjuncts for sleep in FM

0.25-2 mg hs, tabs or quick dissolving wafer for faster onset of action and potentially lower total dosing

Anxiety, Restless leg syndrome, sleep

Cyclobenzaprine/Flexeril

This drug is almost identical to Amitriptyline

5-30 mg at hs

Muscle relaxation, mild pain, sleep
 

Dextromethorphan

Side effect “out of body” feeling.

30-120 mg in 24 hrs

Pain, weak NMDA receptor agonist. Adjunct to Ultram/ Ultracet before moving to scheduled narcotics.

Dicyclomine hydrochloride/Bentyl *

Inexpensive. Well tolerated.

20 mg oral qid

Irritable bowel syndrome/pain
 

Duloxetine hydrochloride/ Cymbalta

Take with food to decrease side effect of nausea.

20-120 mg per day

depression, sleep, pain

Eszopiclone/Lunesta*

Precursor Zopiclone; indicated for long-term use

2-4 mg at hs

Sleep

Ethyl chloride, fluorimethaneÒ spray - termed Spray and Stretch*

Trochanteric bursitis is sometimes mistaken for the greater trochanter trigger point and is effectively treated with local steroid injections. 

Dependant upon body region affected and severity

Muscle pain and myofascial pain syndrome

Fentanyl citrate/Actiq*

Consider limiting use to 6 months.

200 mcq transmucosal

Irritable bowel syndrome/severe pain

Fludrocortisone/Florinef*

Confirm diagnosis of NMH with tilt table test. Refer to John Hopkins website for treatments other than Florinef.

0.1 mg

Adjunct to treating neurally mediated hypotension (NMH), common in patients with fatigue and nausea that are greater than pain

Sodium oxybate/Xyrem

Prescription only available directly through manufacturer due to abuse potential. FDA approved for cataplexy.

4.5-6 mg at hs, repeat 3-4 hours later if needed

Sleep

Gabapentin/Neurontin*

May cause daytime fatigue. Many patients only take an hs dose.

900-3600 mg/day in 3 divided doses

Neuropathic pain

Growth Hormone (e.g., Nutropin)

Not covered by third party payers unless a patient has concomitant adult growth hormone deficiency syndrome.

Values dependent on serum Insulin like Growth Factor levels and body weight. Daily sub-q injections required.

Depression, fatigue, pain, quality of life

Hydrocodone bitartrate/Vicodin

(One of several short acting narcotics)*

Consider moving to long acting when patient using 90-120 tabs/month

Varies with half-life of drug selected and pain level

Moderate Pain

Lidocaine/Lidoderm Patch

Dry needling has been demonstrated to be somewhat effective. Unfortunately, acupuncture was not superior to sham points in FM.

Patch can be applied directly to FM trigger points. Lidocaine can be directly injected in trigger points.

Myofascial pain syndrome

Loperamide/Imodium*

Over the counter. Over use causes constipation. Consider serum testing for celiac sprue if considerable weight loss occurs.

2-4 mg initially, up to 16 mg in 24 hours

Mild IBS diarrhea prone

Lorazepam/Valium

Abuse potential documented in 1970s.

2-10mg up to qid

Sleep, anxiety, muscle relaxation, restless leg syndrome

Methadone/Dolophine*

Patient may resist methadone due to it’s use in heroin withdrawal

5-20 mg bid

Moderate to severe chronic pain

Modafinil/Provigil

Side effects may include headaches or insomnia. Case report supports use in FM.

200-400 mg q am

Severe daytime fatigue and sleepiness. May help fibro fog in some patients.

MS Contin/Kadian*

Do not use in opioid naive patients.

15-60 mg bid

Moderate to severe chronic pain

Non-steroidal Anti-inflammatory agents (NSAIDs)

Overuse may result in rebound headaches. Of minimal relief of FM pain, works in decreasing peripheral pain generation.

Depends on agent chosen

Chronic headaches, tendonitis, concurrent osteoarthritis

Oxycodone/Percocet, Percodan*

Consider if Hydrocodone is inadequately effective.

Varies with half-life of drug selected and pain level

Moderate Pain

Oxycodone hydrochloride /Oxycontin*

Do not chew or break any long acting opioid tablet.

10-30 mg bid

Moderate to severe chronic pain

Pramipexole dihydrochloride/Mirapex

Pilot studies find that high dosages (3.5 mg) improve overall FM symptoms, but require concomitant dosing with a proton pump inhibitor or anti-emetic.

0.125-1.5 mg at dinnertime,

Restless leg syndrome

Pregabalin/Lyrica

Side effect fatigue.

450 mg divided bid

Fatigue, pain, sleep

Pyridostigmine bromide/Mestinon

Improved anxiety, fatigue, sleep and exercise ability, but not pain at rest.

60 mg-180 mg time span bid

Normalize growth hormone response to exercise. May increase ability to exercise with less post exertional pain and fatigue

Roprinirole hydrochloride/Requip

Used to treat overall FM symptoms at higher doses, but limited by side effects of nausea and dizziness

0.5-5 mg at dinner time

Restless leg syndrome

SSRI (selective serotonin reuptake inhibitors - several in this class), those tested in FM, fluoxetine  citalopram hydrobromide/Celexa sertraline hydrochloride/ Zoloft

Improvement in mood may not adequately treat pain and sleep disruption.

Depends on agent chosen

Depression.

 +/- Anxiety

Tegaserod maleate/Zelnorm*

Some patients report lack of ongoing efficacy with this agent. Third party payers may not pay if patient on a narcotic agent.

6 mg bid before breakfast and after dinner.

Irritable bowel syndrome, constipation type

Tiagabine HCl/Gabitril*

Side effects may include fatigue

4 - 56 mg/day given in 2-4 divided doses

Neuropathic pain, sleep

Tizanidine hydrochloride/Zanaflex

Monitor liver enzymes closely

4-8 mg hs

Muscle relaxation, mild pain, sleep, stiffness

Topiramate/Topamax*

Anticonvulsant good for adjunctive pain management

25-100mg

Migraine prophylaxis indication, side effects fatigue & rash

Tramadol hydrochloride with Acetaminophen/ Ultracet

If patient can tolerate 2 tabs simultaneously, may get better pain relief.

37.5 mg every 4-8 hours not to exceed 8 in 24 hours

Mild to Moderate Pain

Tramadol hydrochloride/Ultram

Low abuse potential, nonscheduled drug. Screen for seizure risk if using high dose in conjunction with SSRIs.

50-100 mg every 4-8 h, not to exceed 400 mg in 24 hours

Mild to Moderate Pain

Transdermal Fentanyl (Duragesic Patch)*

All patients on chronic opioid therapy need constipation prophylaxis treatment.

25 mcg/hr change q 3 days

Moderate to severe chronic pain

Trazadone Hydrochloride/Desyrel, Trazon, Trialodine

Side effect of headache keeps some patients from using this agent.

50-150 mg/day hs

Depression, sleep

Zolpidem/Ambien

One of the most commonly prescribed sleep agents. Now available as a generic. Longer acting Ambien CR available as brand name. May need to request “quantity override” for patients to receive > 14 tabs/month.

10 mg hs

Sleep

Zonisamide/Zonegran*

Like many neuropathic pain drugs, Zonegran is FDA approved to treat epilepsy but may help neuropathic pain.

100-400 mg q hs only to minimize side effects of fatigue and dizziness when taken in the daytime

Neuropathic pain