|
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. Adjunct to Ultram/
Ultracet before moving to scheduled opioids |
|
|
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 |
|