Experts discuss the FDA approved agents duloxetine and pregabalin for the treatment of fibromyalgia (FM).
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Any other comments on milnacipran? What about duloxetine? I know for me it's often one of my first choice. It's not a controlled substance like some of the antiepileptic drugs. And I'm comfortable with the prescribing of it. I do push it up to a high of 120 mg in patients with fibromyalgia and chronic pain syndromes. But we must be also cognizant that most of these drugs also have renal dosing. We must be careful with that. Any thoughts on duloxetine?
Kostas Botsoglou, MD: I use it.
Benjamin Natelson, MD: Don't know as I know anything about higher doses and more efficacy. Dan, do you know anything about that?
Daniel Clauw, MD: In the fibromyalgia trials when duloxetine went from 60 mg to 90 mg and 90 mg to one 120 mg, there was a little bit more efficacy, but there were also more side effects. And the FDA, they do that often as they set the highest dose in fibromyalgia 60 mg because they knew there would be dose creep in clinical practice. And duloxetine is approved for other conditions that it's approved for at 90 or 120 mg. We know it's safe at those dosages. And I think that if someone's responding to duloxetine you might try the higher dose if they're not having any side effects of it didn't go as high as 120 mg.
Kostas Botsoglou, MD: I was going to say that in terms of access to very easy to obtain duloxetine. And yes, I tend to go more to the diabetic neuropathy dosing to 120 mg and can do that easily without a prior authorization and so forth.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: The hardest part with this drug is getting people off if you have to take them off. Getting people off of the SNRIs is often a pretty difficult, it requires a very slow taper.
Benjamin Natelson, MD: Absolutely.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Any other comments there? Safety, efficacy concerns? Let's talk about pregabalin. Any thoughts on that?
Benjamin Natelson, MD: It's not the first anti-epileptic drug I'll use cause it's still expensive. I'll use gabapentin first. Gabapentin is not FDA approved, but it's a first cousin. And the problem with gabapentin is you need multiple dosing. And with pregabalin you can get away with 2 maybe 3 doses a day, but I will take people up to 3 g of gabapentin, 5 to 600 mg pills if they can tolerate it. And often at that dose it's helpful. And I won't need to go to a second anti-epileptic. But I feel strongly that using an anti-epileptic of different mechanisms may produce. And it's all anecdotal. Everything I'm reporting to you is my practice and when I add that second anti-epileptic it often helps. And I do that before I turn to opioids. And now having learned from you, Wendy, I'll use memantine first.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Any other, any other thoughts on pregabalin? I mean it was not my first go-to a controlled substance b it was hard to come by. And yes, I can do a lower dose than what I can do with gabapentin, but I often find that the sedation and the dizziness of both pregabalin and gabapentin preclude people from using it. And again, there are renal doses for this. I know gabapentin is now a scheduled drug as well in multiple states. I'm always trying to be cognizant of that as well. Any other doctors?
Kostas Botsoglou, MD: The one I show with pregabalin is it's one of the medications that seems to work the best for my patients, but it's the weight gain that really discourages the,
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Good point.
Kostas Botsoglou, MD: Staying on it. And ultimately, they must get off. We're going on a lower dose because of that.
Benjamin Natelson, MD: And there is one paper that using duloxetine and pregabalin is better than using either alone at high doses. That's worth a try. Also again, I don't use a lot of duloxetine unless there's a coexisting mood disorder but since if there is a mood disorder trying an SNRI, they usually are not as effective in treating. First, the medicines for mood disorder are not all that good unfortunately the difference between the active treatments in depression in the placebo are small relatively but we must be as doctors have to try these in patients that have significant depression as a comorbidity. And I find persistent depressive disorder moderately, often now. I have a tertiary practice of people who've seen a dozen doctors before they've seen me. They've been sick for many years and the illness burden leads to mood changes but again, it's the thing I'm looking for part of my intake is to have them fill out the phq, which is a short questionnaire to diagnose depression and when it's there I think we need to really jump on it and that the primary care doctor can do easily.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Absolutely. I agree with you.
Daniel Clauw, MD: Let me just note the studies with duloxetine show that duloxetine works almost as well in fibromyalgia patients that are not depressed as depressed. We shouldn't use depression as the threshold for saying someone with fibromyalgia should try duloxetine.
Benjamin Natelson, MD: Often.
Daniel Clauw, MD: Works quite well with people that are not depressed. If people should think of it as an analgesic, not as an antidepressant in this setting.
Benjamin Natelson, MD: I'll stand corrected if someone is failing on the anti-epileptic, I think it makes sense to add the SNRI to see if it helps.
Transcript edited for clarity.