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Dean L. PubMed Clinical Q&A [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2008-2013.

PubMed Clinical Q&A.

Comparing Fibromyalgia Drugs

Laura Dean, MD.

Created: June 12, 2011.

Fibromyalgia is characterized by widespread pain as well as other symptoms such as sleep disorders, fatigue, and depression. The cause is unknown but may involve changes to the peripheral and central nervous systems.

Many different types of drugs have been used in an attempt to relieve symptoms of fibromyalgia–these include antidepressants, antiepileptics, and skeletal muscle relaxants. Of the drugs in this summary, only three have been approved by the FDA for the treatment of fibromyalgia: duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica).

The "Drug Class Review on Drugs for Fibromyalgia" compares the safety and effectiveness of 32 drugs. A summary of the findings is below.

How do drugs for fibromyalgia compare in improving symptoms?

Overall, the strength of evidence was low. Of the limited direct comparisons available:

From indirect comparisons (8-15 weeks):

  • For the short-term, duloxetine is better than milnacipran for reducing pain, sleep disturbance, depressed mood, and health-related quality of life. At 28 weeks, however, there were no longer any significant differences between duloxetine and milnacipran.
  • Both duloxetine and milnacipran are better than pregabalin for improving depressed mood, whereas pregabalin is better than milnacipran for improving sleep disturbance.
  • Amitriptyline is similar to duloxetine, milnacipran, and pregabalin on outcomes of pain and fatigue.

Data are lacking for other drugs. [full review]

How do drugs for fibromyalgia compare in safety?

In general, all drugs are well tolerated. Low-strength evidence suggests that overall adverse events are greater with amitriptyline than with IR paroxetine, and with nortriptyline than with amitriptyline. However, there were no significant differences in withdrawals due to adverse events between those or any other drugs. [full review]

Does age, anxiety, or depression influence the safety or effectiveness of fibromyalgia drugs?

Low-strength evidence suggests that response to amitriptyline or cyclobenzaprine does not differ based on age. One small study found that duloxetine was not effective in reducing pain in older nonwhite males, but the study was underpowered to detect any difference.

In adults with anxiety, CR paroxetine and pregabalin improve fibromyalgia pain regardless of baseline anxiety. In adults with depressed mood, duloxetine, fluoxetine, CR paroxetine, and pregabalin all improve pain compared with placebo. Milnacipran was not effective in reducing fibromyalgia pain in nondepressed patients, but this finding should be interpreted with caution due to the small number of patients in this trial. [full review]

Drugs included in this review

Generic nameTrade name
Tricyclic antidepressants
AmitriptylineElavil
DesipramineNorpramin
ImipramineTofranil
Tofranil-PM
Impril
NortriptylineAventyl
Pamelor
Serotonin norepinephrine reuptake inhibitors
DesvenlafaxinePristiq
VenlafaxineEffexor
Effexor XR
Selective serotonin reuptake inhibitors
CitalopramCelexa
EscitalopramLexapro
Cipralex
FluoxetineProzac
Prozac weekly
FluvoxamineLuvox
Luvox CR
ParoxetinePaxil
Paxil CR
Pexeva
SertralineZoloft
Selective serotonin and norepinephrine reuptake inhibitors
DuloxetineCymbalta
MilnacipranSavella
Noradrenergic and specific serotonergic reuptake inhibitor
MirtazapineRemeron
Remeron Soltab
Norepinephrine and dopamine reuptake inhibitor
BupropionWellbutrin
Wellbutrin
Wellbutrin XL
Serotonin receptor antagonist
NefazodoneN/A
Antiepileptic drugs
CarbamazepineTegretol
Tegretol XR
Carbatrol
Equetro
Mazepine
DivalproexDepakote
Depakote ER
Epival
EthotoinPeganone
GabapentinNeurontin
LacosamideVimpat
LamotrigineLamictal
Lamictal ODT
Lamictal XR
Lamictal CD
LevetiracetamKeppra
Keppra XR
OxcarbazepineTrileptal
PhenytoinDilantin
PregabalinLyrica
TiagabineGabitril
TopiramateTopamax
Valproic acid
Depakene
Depacon
Stavzor
ZonisamideZonegran
Skeletal muscle relaxants
CyclobenzaprineAmrix
Flexeril

Further Information

Image th-fibmyalgia11.jpgThis PubMed Clinical Q&A was reviewed by Kimberly Peterson, MS.

For the full report and evidence tables, please see:
Smith B, Peterson K, Fu R, McDonagh M, Thakurta S. Drug Class Review on Drugs for Fibromyalgia [Internet]. Portland (OR): Oregon Health & Science University; 2011 April. Available at http://www.ncbi.nlm.nih.gov/books/NBK55552/.