Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 19
Experts discuss how they personalize treatments for patients with fibromyalgia (FM) and the importance of improving sleep in their approach.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Individualizing fibromyalgia treatment, we've talked about this. We've talked about not ignoring the sleep issue. What is your first go to sleep agent? Is there one that you–I heard cyclobenzaprine. I heard amitriptyline. Are you using the z drugs? Are you using benzos? What are you all doing to help people sleep?
Benjamin Natelson, MD: Xyrem. Oxybate. I find it useful. It's very short acting. A patient may wake in the middle of the night and take a second dose, but because it's so heavily controlled, I don't know how common it will be for the primary care provider. Usually, these sleep medicines put you to sleep, but the patient still reports that they're unrefreshed. And those early studies on Oxybate and FM suggested that it did relieve pain and so that's why I tried it.
Daniel Clauw, MD: But think of Gabapentinoids as hypnotics as well. There were studies that were done showing that about 40, 45% of the benefit of Pregabalin in the fibromyalgia registration trials seemed to be through an improvement in sleep, and people are unaware that although Pregabalin and Gabapentin, when they were approved, were approved as TID, BID drugs. There's a lot of evidence that for pain, the main benefit is to give them a bedtime and that hypnotic affect. And you get a lot of adverse effects by giving people Pregabalin or Gabapentin dose in the morning, but you don't get much benefit from that. I will usually just use a single nighttime dose of a Gabapentinoid and push it up, because you get a lot of side effects from that morning dose that you don't need.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: When you ask someone with fibromyalgia, who also has a concomitant depression or anxiety, do you use Milnacipran because it's sister drug, Levomilnacipran, is approved for depression? It's an SNRI. Do any of you use Milnacipran and Duloxetine to try to optimize both pain, as well as depression and anxiety, or do you combine?
Benjamin Natelson, MD: I use Lamotrigine, which psychiatrists use all the time for mood control. Lamotrigine or Lamictal. I find that drug helpful at moderately high doses and I am willing to try any anti-epileptic drug to see if they'll help pain by reducing the central sensitization process.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I haven't heard you mention Topiramate. Is that in your armamentarium at all?
Benjamin Natelson, MD: Just for headaches. I don't like that. I don't use that drug often.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: OK. What about the rest of you?
Kostas Botsoglou, MD: I agree with Dan. Starting with Gabapentin at night. That's my go to. Also, just because it's easy to obtain and start. And then start a mid-day dose later, but to start at night, especially for sleep.
Benjamin Natelson, MD: 600 mg and then go to 900 mg at night. If that doesn't achieve relief during the daytime, I will start on very low doses. With Gabapentin, I start really with 100 mg in the day, and then ramp up from that, but 600 mg–I don't start with 600 mg at night. I start at 300 mg, then double it and put it up to 900 mg, but then I would use 100 mg doses twice during the day and see whether you can't ramp up without adverse effects. I can do it, but some patients can't tolerate it.
Transcript edited for clarity.