AANP: Fibromyalgia Arsenal Still Worth Considering, Despite New Weapon

INDIANAPOLIS, June 26 -- Pregabalin (Lyrica) just became the first medication approved by the FDA for fibromyalgia-related pain, but it may not work for everyone, so older treatments may still be useful.

In a pair of studies reported last month at the American Psychiatric Association meeting, the response rate varied from about 30% to 60%.

In November 2006, a preliminary report from one of those trials found that 63% of patients reported pain relief with the drug. (See ACR: Lyrica Shows Durable Effect In Fibromyalgia)

So the new drug probably won't make measures clinicians have relied on totally obsolete, Debra Bancroft Rizzo, M.S.N, FNP-C, of the Rheumatic Disease Center in Milwaukee, told attendees at the American Academy of Nurse Practitioners meeting here.

"Pregabalin was previously labeled for treating neuropathic pain associated with diabetic peripheral neuropathy and post-herpetic neuralgia as well as an add-on therapy for adults with partial onset seizures," she said.

The most common side effects of pregabalin, at doses of 300 to 450 mg a day, included mild-to-moderate dizziness and sleepiness. Blurred vision, weight gain, dry mouth, and swelling of the extremities also were reported during trials, Bancroft Rizzo noted. Pregabalin can impair motor function and impair concentration and attention. The side effects appeared to be dose-related, so some suggest starting at 150 mg a day and titrating up from there.

There is also strong evidence that, although an off-label use, antidepressants of the serotonin and norepinephrine dual reuptake inhibitor class can lower pain in patients with fibromyalgia, she said. Among the medications in this class are venlafaxine and duloxetine.

Tricyclic antidepressants such as amitriptyline and cyclobenzaprine in low-doses have also shown good results in reducing pain. Some studies suggest using them in conjunction with selective serotonin reuptake inhibitors (SSRI) such as fluoxetine, which may have an additive benefit.

"The tricyclics are often used to help patients sleep better," she said. "The SSRIs are more stimulating and help with fatigue. Quite often they are used in combination with each other giving the activating one in the morning and sedating one at night."

Exercise is a nonpharmacologic therapy that is useful in treating fibromyalgia. Current suggestions are to begin with low-impact exercise and avoid strength training until later.

Patients should start out exercising 30 to 60 minutes between 2 and 3 times a week, Bancroft Rizzo said. Trying to do too much too fast may actually increase pain.

Many dietary supplements have also been studied, she noted. S-adenosyl-L-methionine 1, 4-butanedisulphonate (SAMe) reduced pain in one study. However, since it included only 15 subjects, the evidence that this supplement works is considered weak.

Herbal remedies such as cayenne or capsaicin have not shown efficacy. The results of 3 acupuncture trials were mixed.

Another tactic, cognitive behavioral therapy, is designed to teach coping strategies, ways to reduce symptoms, and how to identify and then eliminate maladaptive illness behaviors. Although overall behavioral therapy has been shown to be useful in easing the pain of fibromyalgia, its effectiveness is very dependent on the skill of the therapist.

For other coverage of the FDA approval of pregabalin, see .