Q: What are the best treatment options for fibromyalgia? I have been taking gabapentin for two months and I am barely noticing any improvement in my pain.
Fibromyalgia is a chronic condition that can be difficult to manage. It primarily causes widespread pain in muscles, ligaments, and tendons, but it can also affect bones, joint, and nerves. What many people don’t realize is that fibromyalgia often comes with a wide range of other symptoms including fatigue, trouble sleeping, trouble thinking clearly or remembering things, anxiety, and depression. It is also commonly linked to other conditions such as migraine headaches, irritable bowel syndrome, and severe menstrual pain.
Because fibromyalgia can present differently from person to person, how it is treated can also be different. The best treatment plan should depend on what you identify as your most bothersome symptoms. When starting medication therapy the treatment goal should be improving your overall function and quality of life as opposed to eliminating pain. At best medication therapy is reported to be moderately effective at reducing pain in less than half of people using it to treat fibromyalgia.
For the medications I’ll be discussing, it is important to start them at the lowest dose and slowly increase it based on your response and how well you tolerate it. Increasing your dose too quickly may lead to side effects that could limit your ability to continue the medication or increase the dose further.
Gabapentin is often used when nerve pain in your primary symptom. Doses for fibromyalgia range from 1,200 to 2,400 mg per day. Pregabalin is a similar medication with doses reaching up to 450 mg per day. Some people find pregabalin slightly more effective than gabapentin for pain relief, though this varies from person to person. In addition to reducing pain, both medications can also help improve sleep which can lessen fatigue.
When pain is accompanied by a mood disorder, duloxetine is often the preferred medication at a dose of 60 mg per day. Duloxetine addresses both pain and mood symptoms and may also provide mild benefits for sleep and overall function.
Amitriptyline may be used on its own for widespread pain without other troublesome symptoms or it may be added on as an additional pain reliever. It is typically taken in the evening at doses up to 30 mg, although higher doses can lead to troublesome side effects for some people including dry eyes, dry mouth, constipation and urinary retention.
Cyclobenzaprine is another option that can be used for the same indications as amitriptyline. For fibromyalgia it is usually prescribed at doses of 20 to 30 mg per day. It works by relaxing muscles, which can relieve pain and improve sleep, factors that may also help to reduce fatigue.
When sleep disturbances are a major concern, sometimes nabilone, a synthetic cannabinoid in pill form available by prescription and dispensed through the pharmacy, may be considered. Other cannabinoids like THC and CBD can be accessed through non-pharmacy dispensaries, such as Cannabis NB. Although there is emerging research suggesting potential benefits for pain management, more evidence is needed before firm recommendations can be made for fibromyalgia.
Regarding your use of gabapentin, the first step is to determine whether it’s addressing your most bothersome symptoms. If it seems appropriate but ineffective, it may be worth considering a higher dose or switching to pregabalin.
In addition to medications, incorporating physical activity into your treatment plan is essential. Many people with fibromyalgia are understandably hesitant to exercise, fearing it might worsen their pain, fatigue, or disability. Cognitive-behavioural therapy (CBT) can he a helpful tool to overcome this fear. CBT can also support the management of anxiety, depression, and other emotional challenges that can be associated with chronic pain.
Research shows that regular exercise can lead to improvements in pain and physical function over time. It’s important to start slow - even a few minutes at a time is a good place to begin. Recommended activities include low impact aerobic exercises, swimming, yoga, and tai chi. These activities can also help with sleep and fatigue.
Another non-medicinal option that you could add to your treatment plan is acupuncture, which may offer additional relief from pain and help improve sleep quality.
Erin Thompson (BSc, BScPharm) is a graduate of Dalhousie University and a community pharmacist practicing at Shoppers Drug Mart in Quispamsis N.B. Her opinions expressed in this column are published for educational and informational purposes only, and are not intended as a diagnosis, treatment or as a substitute for professional medical advice, diagnosis or treatment.