Current Drug Therapies for FM/CMP by Devin Starlanyl

BD14565_.GIF (852 bytes)Medication FAQ'S     BD14565_.GIF (852 bytes)Current Drug Therapies for FM/CMP by Devin Starlanyl
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Medications are one way you can gain some control over your symptoms. They may enable you to handle a greater amount of bodywork and exercise, and can be used to restore greater levels of function. Until recently, much of the medical world regarded complaints caused by FMS and CMP as psychological. One result of that attitude is that very few drugs are established as effective in these conditions. Medications developed for other conditions may often prove helpful. Antidepressants have pain-relieving effects independent of changes of mood, for example, and in lower doses than used to treat depression (Fasmer, 1990) and may be effective in reducing pain associated with FMS (Fishbain, 2000). Medication should never be considered as the only form of pain control. It must be part of a global strategy, with sound nutrition, bodywork, mindwork, lifestyle adjustments, and other non-medicinal options of pain control.

Before adding any new medication, review your current meds with your doctor. Discuss your options. Address all perpetuating factors. For example, you may have been put on Tagamet, Zantac or Prilosec for heartburn and esophageal reflux. These can decrease your ability to digest foods, and add to your symptoms in the long run. If you have reflux, look into the possibility that you may have insulin resistance/reactive hypoglycemia. If you crave carbohydrates and have other symptoms of these conditions, try diet modification. Eliminate excess carbohydrates. Check for possible TrPs in the area around the base of your breastbone. With a change of diet and some myotherapy, you may be able to avoid these expensive medications.

Medications that affect the central nervous system are appropriate for FMS. These meds target insomnia, pain, and fatigue. Pain sensations are amplified by FMS, so if you have TrPs or other instigators, your total pain level may be severe. FMS patients may react in an unusual manner to medications. Keep careful records of your medicines using a medical use form such as the one in "The Fibromyalgia Advocate". There is no cookbook recipe for prescribing medications for FMS and CMP. A medication that works well for one person can be completely ineffective for another. It is important that you don’t mix nonprescription medications, such as herbal remedies, with your prescription medications without discussing it with your health team first.

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Over the Counter (OTC) Medications and Supplements

Benadryl (diphenhydramine): This sleep aid/antihistamine is safe to take even during pregnancy. The starting dose is 50 mg, taken 1 hour before bed. About 20 percent of patients are stimulated rather than sedated by Benadryl. Patients have reported urinary hesitancy on this medication.

Calms Forte: This mix of herbs and minerals may be effective to promote sleep.

Chromium Picolinate: This may decrease carbocraving. It seems to improve the efficiency of insulin (Striffler, Law, Polansky et al. 1995).

Coenzyme Q10 is a vitamin-like substance. Some people have found it helps reduce fibrofog. It’s an important part of the mitochrondrial membrane, but we don’t understand its functions.

DHEA (dehydroepiandrosterone) turns into estrogen and testosterone in your body. High doses (25-50 mg/daily) can trigger heart irregularities, or even a heart attack. (Sahelian and Borken, 1998). Some FMS patients report it helps them feel better.

Digestant Enzymes: If you have problems digesting foods, try taking papain or a natural enzyme combination to help your gastrointestinal system break down foods.

Glucosamine and chondroitin: These may be beneficial in cases of inflammation, bone or cartilage degradation, or problems with ground substance. Glucosamine may cause worsening of symptoms for FMS patients with high levels of hyaluronic acid (see New Research)

5-Hydroxytryptophan (5-HTP): Your body converts this to serotonin. It easily crosses the blood-brain barrier and effectively increases synthesis of serotonin (Birdsall, 1998).

Human Growth Hormone (HGH, somatotropin): This hormone is converted into insulin-like-growth-factor-1 (IGF-1). There are dangerous implications with OTC use (Ng, Ji, Tan et al.1998). The use of OTC growth hormone is not to be confused with the legitimate FMS research that has uncovered a subset of FMS patients who have low IGF-1. This deficiency occurs in about 30 percent of FMS patients (Bennett, 1998). Replacement treatment for these patients improves some FMS parameters.

Melatonin: Melatonin is a neurotransmitter that the body changes into serotonin. It may help reduce tender point count and severity of pain as well as improve sleep significantly in FMS patients (Citera, Arias, Maldonado-Cocco et al. 2000). Patients with FMS may have low melatonin secretion during the hours of darkness. This may contribute to poor sleep, fatigue, and enhanced pain (Wikner, Hirsch, Wetterberg et al. 1998). Melatonin in sufficient dosage may inhibit ovulation. Up to one-third of those who try melatonin become depressed. If depression occurs, stop taking it immediately and alert your doctor. Melatonin should not be taken by people with autoimmune conditions (Lapin, Mirzaev, Ryzov et al. 1998). Melatonin may help reduce seizure-like symptoms.

NSAIDS: Nonsteroidal anti-inflammatory agents (NSAIDS) can be effective in cases of inflammatory pain, but neither FMS nor CMP are inflammatory. NSAIDs include medications such as aspirin, ibuprofen, acetaminophen and naproxen. NSAIDS have serious side effects including: asthma, cell toxicity; and chromosome abnormalities (Leach, Frank, Berardi et al. 1999). A large majority of the patients who develop serious GI complications on NSAIDS have never had previous mild side effects. Treatment with antacids and H2 receptor antagonists may increase the risk for subsequent serious GI complications (Singh, Ramey, Morfeld et al.1996).

Malic acid and magnesium: Malic acid plays a key part in the metabolism of carbohydrates, as well as in the formation of ATP. Magnesium and B6 are needed for malate to work in energy production (Lowe, 2000). One study showed that this combination is safe and may be beneficial in the treatment of FMS (Russell, Michalek, Fletchas et al. Abraham, 1995).

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Prescription Medications
Pharmacies and Pharmacists

Have all your prescriptions filled at one pharmacy so your pharmacist can warn you of any possible drug interactions, no matter how many doctors you have. Your pharmacist can be a great ally and teacher. Learn about your medications. Develop a working relationship based on mutual respect and trust. Educate your pharmacist about FMS and CMP. The handout "What Your Pharmacist Should Know" from The Fibromyalgia Advocate may be helpful. If your pharmacist treats you like a drug addict or malingerer, let him/her know that this is inappropriate, and that you do not allow inappropriate behavior from health care providers.

Compounding Pharmacists

Compounding pharmacists are different than standard pharmacists. They are like the ancient apothecaries, only with all the present day knowledge and technology available. All pharmacists learn something about compounding prescriptions, but compounding pharmacists are specialists in the formulation of pharmaceutical compounds from basic ingredients, in the exact dosage form, strength and combination you require. You may need a dye-free, sugar-free, alcohol–free or preservative-free formulation, for example.

When you take a medication orally, you dose the whole body. Often this is not necessary for localized symptoms. It isn’t sufficient for any pharmacist to put a drug into topical form. This drug must be bioavailable in this form, and a true compounding pharmacist knows how to do this. Standard topical preparations compounded include NMDA- and Calcium Channel Blockers, medications such as Neurontin, NSAIDs and opioids. Your doctor may not be utilizing this option, and you may be able to provide him/her with an important contact.

Generic Medicines

Generic and brand name drugs are not always exact equivalents. Some FMS and CMP patients may be sensitive to the differences. The generic company must prove to the FDA that when someone takes the drug, the amount of the active substance released by the generic is the same as would be obtained with the brand- name drug (that it is bioequivalent). Doctors and patients are led to believe that this means the generics are the same as the brand names. This is not always true. The FDA considers two formulations as bioequivalent when the rate of adsorption varies no more than -20% or +25% (Banahan, Kolassa 1997). This means that there can be 20 percent less usable medication in a dose, or 25 percent more!

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Prescription Medications List

This list of medications is only a partial listing of those used in FMS and CMP, and doesn’t even include all that we have in our book. For details on the use of common pharmaceutical and non-pharmaceutical medications for chronic pain, see The Chronic Pain Control Workbook (Catalano and Hardin, 1996) and Pain: Clinical Manual (McCaffery M. and C. Paseo, 1999).

Ambien (zolpidem): This is a hypnotic for insomnia. It can be a tremendously effective sleep aid, but you may have to get in bed right after you take it. One study showed that short-term treatment with Ambien (5 to 15 mg) doesn’t affect FMS pain, but is useful for sleep and subsequent daytime energy (Moldofsky, Lue, Mously et al. 1996). William Dement, the father of the field of sleep medicine, writes that Ambien is the safest and most useful sleep medication for long-term use as well (Dement and Vaughan, 1999). There have been some reports of serious depression from Ambien. Some patients have reported difficulty discontinuing it, and had to decrease it by a quarter pill a night. Others have had no problem. I have had an alarming number of people contact me saying that their doctors have refused to prescribe this medication because it is addictive, in spite of the fact that studies show that it has a lower abuse potential than other hypnotics (Soyka, Bottlender and Moller, 2000).

Atarax (hydroxyzine HCl): This antihistamine and anxiety-reliever may be useful if itch, rashes or hives is a problem.

BuSpar (buspirone HCl): This drug may improve memory, reduce anxiety, and help regulate body temperature. It is not as sedating as many other antianxiety drugs.

Catapres (clonidine): This drug may help Restless Leg Syndrome (RLS)(Wagner, Walters, Coleman et al. 1996).

COX-2 medications: Ariva, Vioxx, and Celebrex are sometimes called super aspirin. They are easier on the gastrointestinal tract than earlier NSAIDS. They may carry a greater risk of heart attack, stroke, or other cardiovascular problem (McAdam, Catella Lawson, Mardini et al. 1999).

Desyrel (trazodone): This antidepressant may help with sleep problems. It must be taken with food. It should not be used in women who may be or may become pregnant.

Diflucan (fluconazole): This antifungal penetrates all body tissues, including the central nervous system. Very short-term use can be considered if cognitive problems and/or depression are present and yeast is suspected. Yeast problems may indicate need for diet modification.

Effexor (venlafaxine HCl): This is an antidepressant and serotonin and norepinephrine reuptake inhibitor. Food has no effect on its absorption. When discontinuing this, taper off slowly.

Elavil (amitriptyline): This antidepressant is inexpensive, but it can cause photosensitivity, morning grogginess, weight gain, dry mouth, and slow intestinal movements. It may cause RLS.

Flexeril (cyclobenzaprine): This may sometimes stop spasms, twitches, and some tightness of the muscles. It generates stage-four sleep, but it may cause gastric upset and a feeling of detachment.

Ethyl Chloride: This vapocoolant spray is useful for spray and stretch treatment, to inhibit pain impulses, and to allow for passive stretching.

Guaifenesin: Guaifenesin is the active ingredient in many expectorants, and is used experimentally for FMS. Most OTC guaifenesin preparations contain sugar, alcohol, and/or pseudoephredine. These should be avoided.

Inderal (propranolol HCl): This may help reduce the pain load, although your blood pressure may drop with its use. Antacids will block its effect.

Klonopin (klonazepam): This is an antianxiety, anticonvulsive and antispasmodic medication. It may help with muscle twitching, RLS, and nighttime teeth grinding.

Lidocaine, intravenous: Studies show that in animals, intravenous lidocaine can provide prolonged relief of some types of allodynia (Chaplan, Bach, Shafer et al. 1995).

Neurontin (gabapentin): This anticonvulsant is effective for hyperalgesia and allodynia (Attal, Brasseur, Parker et al. 1998.) You may be able to lessen any side effects by drinking extra water. As dosage increases, bioavailability decreases. A 400 mg dose is about 25% less bioavailable than a 100 mg dose. This medication should not be discontinued abruptly.

Opioids: Due to the fact that some doctors consider the use of opioids to be controversial in the treatment of FMS and CMP, these medications are covered in depth at the end of this list.

NMDA (N-methyl-D-aspartate) inhibitors: NMDA antagonists can moderate or eliminate some symptoms of central sensitization, such as secondary hyperalgesia (Oestreicher, Desmeules, Piguet et al.1998.) NMDA inhibitors include ketamine, dextromethorphan, memantine, amantadine, methadone, dextropropoxyphene, and ketobemidone. NMDA-receptor inhibitors may be effective in the treatment of some types of chronic pain (Sang, 2000). Ketamine reduces pain in a sub-group of FMS patients (Graven-Nielsen, Aspegren, Henriksson et al. 2000). NMDA inhibitors also boost the effect of opioids.

Pamelor (nortriptyline HCl): This tricyclic antidepressant is used for insomnia. Some people find it stimulating, however, and must take it in the morning to allow restorative sleep that night.

Paxil (paroxetine HCl): This SSRI may also reduce pain, and has been found helpful in menopausal hot flashes (Gender Issues). Some people find it stimulating, and may need to take it in the morning to allow for sleep that night.

Piracetam: This is an extract of ginko biloba. It seems to step up the flow of messages between the two halves of the brain (Flicker and Grimley Evans, 2000). It may stimulate the cerebral cortex and increase the rate of metabolism and energy level of brain cells.

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Procaine injection for TrPs: TrP Injection protocols can be found in Travell and Simons Trigger Point Manuals. TrP injections must be given in the proper manner, with the patient properly positioned for each specific muscle, and performed with spray and stretch, rewarming, and range of motion exercises. Perpetuating factors must be addressed for lasting effects. TrP injections are not to be done with steroids.

Relafen (nabumetone): This NSAID may be better tolerated because it is absorbed in the intestine, thus sparing the stomach.

Remeron (mirtazapine): This antidepressant is unrelated to SSRIs, tricyclics or MAO inhibitors. It seems to cause fewer occurrences of common side effects.

Restoril (temazepam): This hypnotic may be useful to improve sleep. There are few reports of "hangover" effect.

Serzone (nefazodone HCl): This antidepressant is unrelated to SSRIs, tricyclics, or MAO inhibitors. It inhibits serotonin and norepinephrine, but has a low bioavailability that varies.

Sinequan (doxepin HCl): This tricyclic antidepressant and antihistamine combination can cause sedation. It may enhance the effects of Klonopin, and can reduce muscle twitching by itself.

Soma (carisoprodol): This central nervous system muffler works rapidly. Effects last from four to six hours. It helps patients to detach themselves from their pain, and can damp the sensory overload of FMS. It should not be used as the only pain control. There are some reports of dependency. It can cause respiratory depression given in conjunction with propoxyphene. Treatment of FMS with the combination of carisoprodol, acetaminophen and caffeine is effective (Vaeroy, Abrahamsen, Forre et al. 1989).

Sonata (zaleplon): This is a short–term-acting hypnotic. You don’t have to take it every night if you don’t always have insomnia, because you can take it at bedtime or even later on those nights you have difficulty. You do need four hours to sleep it off (Elie, Ruther, Farr et al.1999).

Ultram (tramadol HCl): This medication for moderate to severe pain acts on the central nervous system. It may cause constipation, nausea, dizziness, headaches, weariness, tightening of jaw and neck muscles, and vomiting. Some doctors have reported psychological addiction to Ultram that is even harder to break than narcotic addiction. This medication can lower the seizure threshold.

Wellbutrin (bupropion HCl): This antidepressant is sometimes used in FMS in place of Elavil, but it can promote seizures.

Xanax (alprazolam): This anti-anxiety medication may be enhanced by ibuprofen. It aids the formation of blood platelets, which store serotonin, and it raises the seizure threshold. It must not be used during pregnancy. When you stop taking it, taper off gradually.

Zanaflex (tizantidine hydrochloride): This muscle relaxant may help with RLS. It may help to reduce muscle tightness, and may have sedative effects. This is another medication you may have to take just before bed, as there have been reports of loss of muscle control. Some patients also mention hallucinatory effects.

Zofran (ondansetron) This medication helps about 50% primary FMS patients, according to one study (Hrycaj, Stratz, Mennet et al. 1996). The response was not the same in post-traumatic FMS.

Zoloft (sertraline HCl): This is commonly used to help with sleep problems. There have been several reports of night sweats with strong ammonia odor. It may be useful for PMS (Yonkers, Halbreich, Freeman, et al. 1997).

Most people who find Benedryl stimulating rather than sedating seem to have the same response to Pamelor, Paxil, and Ultram. I don’t know why, but I suspect it may be a clue to the parameters of a subset of FMS.

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Medications, Pain and Opioids

Too often readers have told me, "My doctor would not prescribe this medication because it is too hard to get someone off it." It’s hard to stop taking a medication that will relieve your pain. It’s nearly as hard as trying to figure out why any doctor in his/her right mind would want you to do so. In the best of all worlds, early FMS and single TrPs would be promptly diagnosed and treated. In our present reality, central sensitization and allodynia of FMS coupled with the pain generated by TrPs can make this world a living hell for patients who haven’t been promptly diagnosed and treated. We must deal with reality as it is today, unhampered by outmoded belief systems. Pain control is imperative to reduce any further sensitization of the nervous system, as well as to allow
appropriate bodywork without  additional shock to the pain sensing system.

I am not advocating opioids as the first method of pain control, or as the singular method of pain control. When other options have failed, medical literature documents that opioids, in conjunction with a thorough pain control program including bodywork, mindwork and life style adjustment, are a logical and humane option in the treatment of severe FMS and CMP. The rest of this section will be from medical journal articles. For more information on this subject, see "The Fibromyalgia Advocate".

The treatment of non-cancer pain with opioids may work for patients who don’t gain sufficient reduction of pain by other therapies (Dertwinkel, Wiebalck, Zenz et al.1996).

Opioids may be the only hope of relief to many people with chronic pain (Shannon and Baranowski). 1997).

Higher levels of opioid use are not associated with higher levels of disability or depression (Ciccone, Just, Bandilla, et al. 2000).

Chronic opioid use at the proper dosage, tailored to patients’ need and tolerance, did not significantly impair  perception, cognition, coordination, and behavior. (Galski, Williams and Ehle, 2000).

From a purely pharmacological point of view, opioids have perhaps the best side effect profile of any drugs we have available form pain (Horning, 1997).

Unlike the chemically dependent patient whose function is impaired by medications, the chronic pain patient’s level of function may improve with proper use of medications, including opioids (Seas and Clark, 1993).

Addictive behaviors aren’t common in chronic pain patients (Fishbain, Rosomoff and Rosomoff, 1992).

There are possible side effects with opioids, and some people do have a tendency towards addiction, but, according to these and many other references, this is not common in chronic pain patients. Opioids often slow intestinal motility. Measures should be taken to prevent constipation. Temporary sleepiness and confusion is common after initial opioid therapy, and after dose increases. Nausea may occur for the first 3 or 4 days.

Some opioids are available in suppository form if nausea and vomiting is present. Transdermal patches are also available. The liquid form may be very useful because of the ease with which you can vary the dose. For example, hydromorphone hydrochloride 5 mg per ml is available. My doctor suggests this form because it isn’t combined with NSAIDS, and because you can adjust the dosage. On days when pain is severe you may need your full dose, but on good days you can take a lesser amount.

Excerpted from "Fibromyalgia and Chronic Myofascial Pain: A Survival Manual (Chapter 21) edition 2" by Devin J. Starlanyl and Mary Ellen Copeland coming June 2001. (Vitamins and minerals are addressed in Nutrition chapter.)

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