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Most common oral medications used in fibromyalgia in adults

Most common oral medications used in fibromyalgia in adults
Clinical use Drug class Medication Dose (adult)
Most common: Diffuse, widespread pain without major comorbid mood or sleep disturbances Tricyclics* and related medications Amitriptyline
  • Start at 5 to 10 mg taken 1 to 3 hours before bedtime
  • Increase by 5 mg no more frequently than every 2 weeks
  • Use the lowest dose possible, generally between 20 and 30 mg
Cyclobenzaprine
  • Start at 5 to 10 mg taken 1 to 3 hours before bedtime
  • Increase by 5 mg no more frequently than every 2 weeks
  • Use the lowest dose possible, generally between 10 and 20 mg
Severe fatigue and/or depression Selective serotonin-norepinephrine reuptake inhibitor (SNRI) Duloxetine
  • Start at 20 to 30 mg in the morning with food
  • Increase by 20 mg every few weeks to 60 mg daily as tolerated
  • Doses as low as 20 to 30 mg daily may be effective for some patients
Milnacipran
  • Start at 12.5 mg in the morning
  • Increase by 12.5 mg every few weeks to 50 to 100 mg once or twice daily as tolerated
Prominent sleep disturbance Alpha 2 ligands PregabalinΔ
  • Start at 25 to 50 mg at bedtime
  • Increase by 25 to 50 mg every 2 to 4 weeks to 300 to 450 mg daily (in 1 or 2 divided doses) as tolerated
GabapentinΔ
  • Start at 100 mg at bedtime
  • Increase by 100 mg every 2 to 4 weeks to 1200 to 2400 mg daily (usually in 2 or 3 divided doses) as tolerated
To be used with UpToDate content on treatment of fibromyalgia. The doses recommended in this table are intended for patients with normal kidney and liver function. For dose adjustments in kidney or liver impairment, refer to the drug monographs included within UpToDate.

* The use of tricyclics may be limited by anticholinergic effects (eg, dryness, urinary retention), central nervous system depression, and orthostatic hypotension to which older adults are particularly susceptible. Use of low doses and gradual titration as listed above may improve tolerability.

¶ Patients with major mental health disorders and/or primary sleep disorders (eg, sleep apnea, restless legs syndrome) should be referred for appropriate treatment of these comorbid conditions.

Δ Clearance of pregabalin and gabapentin is highly dependent upon kidney function; refer to drug monographs for specific dose adjustments in chronic kidney disease and age-related declining kidney function.

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