Experts discuss the FDA approved agent milnacipran for the treatment of fibromyalgia (FM).
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Let's talk about the safety and efficacy and the data of the three approved agents. Can we start with the first one to come out which or some of the earlier data on milnacipran, anyone want to talk about that and how they use it and dosing, et cetera?
Daniel Clauw, MD: I had a lot of experience in helping develop helping find it in France and then helping develop milnacipran. I know a lot about the drug. It is a serotonin, norepinephrine reuptake inhibitor that is more noradrenergic than most of the other ones than venlafaxine than duloxetine and there is a lot of evidence in the broader pain field that norepinephrine is the more important of the 2 neurotransmitters of neurophine and serotonin. Then some of the drugs that are pure norepinephrine reuptake inhibitors are effective in pain you don't even need any serotonin, whereas the highly selective serotonergic drugs are not effective. The nice thing about milnacipran is that it's a serotonin norepinephrine reuptake inhibitor that's more neuregic than pretty much any of the other SNRIs. And that's sort of like a profile where people that have more fatigue, more memory problems, things like that might be more likely to respond to it. It might be but people also will have slightly more like palpitations and more hyperallergic side effects as well from milnacipran than they do from some of the other drugs.
Benjamin Natelson, MD: And I guess the other problem with using it Dan, is getting the patient up to therapeutic levels with the GI issues. That's been a significant problem and it really has made it for me the last of them to try. I'll try other SNRIs first, but I think you're right. Your point is well taken and that maybe I should just try it more and just started lower just ramp up slower.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I generally start at 12.5 mg. And do you push them up to 100 mg? Is that where you try to get people?
Daniel Clauw, MD: Just put it big in the one of the problems with milnacipran is it's still it's an immediate release drug and the SNRIs are a lot less GI toxic when they're extended release. Like it, some of you might be old enough to remember when venlafaxine first came on the market, we called it side Effexor because but until they came out with the extended-release form, and it was way better tolerated. The problem is the current form of milnacipran is immediate release. Taking it with a full stomach or doing things that would make it more extended release will help a lot with the GI tolerability issues. But that is just sort of like inherent to the drug.
Transcript edited for clarity.