Experts discuss their therapeutic approach and key agents utilized in the treatment of fibromyalgia (FM).
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: We've all listed a bunch of therapies that we use both medically as well as those supporting therapies. What is it like for your patients in terms of combining therapies? Do you think that's the norm? And what is your go-to combination if you have one?
Daniel Clauw, MD: If you must use more than one drug. The real problem in a lot of these patients is polypharmacy, is that each provider adds layers on a drug, and they don't know if it worked or not. But let's say that someone does need 2 medications. One would be a hypnotic at bedtime that's helping them sleep, and that you can use a gabapentinoid in that way. You can use a tricyclic in that way, but those are hypnotics that will also help pain. And then often you do have them on something in the morning, ASNRI duloxetine, milnacipran in the morning, that'll help more with the fatigue, the memory problems, especially milnacipran is more noradrenergic. And in people that have a lot of fatigue or memory problems, they might find that even more beneficial than duloxetine.
Benjamin Natelson, MD: I personally have a step approach to managing pain. I decided my first drug will depend on if the patient has a concurrent mood disorder. And mood disorders are very common, and I'm very sensitive to mood disorders because they add rocks to the rucksack of suffering, if you will. What I will do is I'll use duloxetine if there's a mood disorder, and if there's not a mood disorder, I'll start with an antiepileptic like pregabalin or gabapentin, and then I'll take those drugs up to rather high doses the antiepileptic to rather high doses that surprise some colleagues, because I'll just go on until there's side effects or improvement. And then I will add a second anti-epileptic drug. And so, if I use the pregabalin or gabapentin, I'll switch to perhaps lamotrigene oxcarbamazepine, and I'll take those drugs up to therapeutic levels also. And then if a patient is still suffering, I may try an unproven treatment. But there is some data on it, which is called low-dose naltrexone. Naltrexone at high doses is an opiate blocker, but the current belief is at 4 to 2 to 6 mg, it's immune modulating. And I'll have a patient try that. And then if they still have so much pain that they're bedridden, I will then turn to opioids. And I will say that that's maybe 10 or 15%. At Mount Sinai where I am, the anesthesiologist no longer prescribes opioids. And indeed, when things changed at Mount Sinai, when it went from team A to team B, team A used a lot of opioids, team B used no opioids, and suddenly patients were withdrawn, if you will. So, I think there's an appropriate role for a small number of patients. And I have a small number of patients in my practice who've been unstable doses of opioids for many years, and they help.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Dr Botsoglou?
Kostas Botsoglou, MD: Back to Ben's point I feel like a lot of the referrals that come in, these patients are already on anticonvulsants, usually gabapentin, and they haven't really been maxed out or taken to higher titrating doses. And I like to at least maximize with the anticonvulsants. Otherwise, I might consider adding a muscle relaxant such as cyclobenzaprine to help them with sleep as well.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Excellent. I agree with those. I'm wondering just we're going to get into this. Have any of you done anything with Mementine or Namenda that Mementine product?
Benjamin Natelson, MD: Yes, I use it. I usually don't use it right off the bat. I usually use it when people on opioids are still having pain. I added up to 10 milligrams twice, have you used it before opioids successfully?
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I've used it before, opioids before I go that route. Often when they're on an SNRI of some sort duloxetine or milnacipran, add on a low dose muscle relaxant at bedtime. But I've added it on, and I've also used it with low-dose naltrexone as well.
Benjamin Natelson, MD: And you find that it's helpful with pain because?
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I've found that it's been helpful. And I would tell you I probably have an N of 20 or 30, but I've found that many of them have found benefit from it.
Daniel Clauw, MD: It's just not your anecdotal experience. There is a randomized controlled trial that showed it to be a benefit.
Benjamin Natelson, MD: Dan, do you use it in your course of treatment?
Daniel Clauw, MD: I don't see patients anymore. But I'd use it right before an opioid. I hate opioids and fibromyalgia. I think it's a terrible idea. Well, I agree that there's a subset of people with pain that need an opioid, but I think this is just a particularly dangerous group of patients to give an opioid too.
Kostas Botsoglou, MD: Is there a role?
Benjamin Natelson, MD: I haven't had any problems with the small numbers of patients who've on been on opioids for years.
Daniel Clauw, MD: I'm talking about data and not anecdote like all mortality of you increases in all-cause mortality. It doesn't matter what you think anecdotally, the data suggests that opioids are killing people at high rates in chronic pain patients that are taking them as prescribed.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I think Dr Botsoglou had a great question for the group, and that is the role of cannabis. Is that what you just asked, sir?
Kostas Botsoglou, MD: Is there a role for CBD or medical cannabis for these patients? Given that we are limited in options.
Daniel Clauw, MD: There are a couple studies with Nabilone RCTs, real trials of Nabilone and showed it to be somewhat effective, but it has a lot of side effects. Just like if you give someone any THC containing cannabinoid, there's a very narrow therapeutic window for THC be the amount that helps versus the amount that causes impairment or gets people high. We have a lot of ANH funding in cannabinoids right now. I'm a lot more excited about cannabidiol or CBD than I am about the THC containing cannabinoids. Again, because the therapeutic window for THC is so narrow and the oral preparations have such different bioavailability depending on whether it is an empty stomach or a fatty meal or whatever.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: The hardest part for me about CBD and cannabis is I have used it, but it's so variable. Every product is so different that there's such little regulation of these products that I have no idea if they're going to work or not work. That's the hard part.
Kostas Botsoglou, MD: Agree. And we're relying on the pharmacist to help us with the titration.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Or the ombudsman that are in some of these cannabis dispensary facilities who are often 25-year-old kids trying to match up a brownie to a gummy bear. It's so very difficult to figure it out medically, an evidence-based like for me, it's hard anyways. But I have had patients who have said that it's helpful, but not everyone.
Daniel Clauw, MD: It may be Illegal throughout the United States because of the hemp bill. CBD, derived from hemp is what you're getting. It's labeled and things like that. And so, people shouldn't be getting any cannabis products from unknown sources, but you don't really have to anymore. Again, with cannabidiol, it's not illegal. It's not derived from cannabis; it's derived from hemp.
Transcript edited for clarity.