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TCAs best in fibromyalgia?

The Journal of the American Medical Association has published the results of a meta-analysis to determine the efficacy of antidepressants in treating the major symptoms of fibromyalgia.

Fibromyalgia is a chronic pain disorder associated with multiple debilitating symptoms and high disease-related costs. This analysis reviewed randomised controlled trials of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs).

Overall, treatment was associated with a statistically significant reduction in pain, fatigue, depressed mood and sleep disturbance. There was also an improvement in health-related quality of life.

When analysed separately, the pain benefit effect size was largest for TCAs (Standardised Mean Difference -1.64, 95% CI –2.57 to –0.71). The effect was moderate with MAOIs (SMD, –0.54; 95% CI, –1.02 to –0.07) and smallest with SSRIs (SMD, –0.39; 95% CI, –0.77 to –0.01) and SNRIs (SMD, –0.36; 95% CI, –0.46 to –0.25). SSRIs were better for depressed mood and SNRIs were better for sleep disturbances.

The authors conclude that antidepressant medication is associated with improvements in outcomes. They also note that all of the studies were relatively short in duration and therefore further work is recommended to examine long term benefits.

Action: Clinicians may find this review useful in aiding treatment choice depending upon symptom presentation. TCAs would appear to be a good first line choice for pain reduction and may have been ranked less effective in depression as a consequence of the low doses used to treat pain symptoms.

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2 Comments to “TCAs best in fibromyalgia?”

  1. The Unique Pain Of Fibromyalgia Syndrome

    The experience of pain appears to be a complex phenomenon with humans. The reason for the occurrence of pain can be physical, psychological, or a combination of both of these causes. And how one defines or describes the intensity of the pain they experience varies as much as the types of pain that exist. Although the origin may be the same from one person to another, the experience of pain is, in fact, a subjective emotional response to the sensation and perception of the pain itself.
    This is why the syndrome of Fibromyalgia is so difficult to define objectively and treat for health care providers, who are usually primary care physicians. Rheumatologists have said that Fibromyalgia Syndrome is the second most common musculoskeletal diagnosis after osteoporosis.
    Fibromyalgia is a very controversial syndrome. Some doubt it is as prevalent as others believe (3 to 6 percent of the population, some have determined). About 80 percent of the sufferers that are diagnosed with fibromyalgia are women. Furthermore, fibromyalgia is not a disease- it is a syndrome. A syndrome is what you call something that has multiple symptoms that occur together. A disease, however, is an actual dysfunction of one’s physiology in some manner.
    Fibromyalgia syndrome is considered a muscle condition that involves varying intensities of chronic pain for a prolonged period of time. As a result of this pain which is rather brutal with many sufferers, their physical function becomes limited. In addition, the location of the pain associated with fibromyalgia is determined by the health care provider according to at least 11 of 18 defined tender points at various locations on the human body.
    Regardless, fibromyalgia is misunderstood by the medical community overall. To further complicate the subject of fibromyalgia syndrome, some have suggested that the pharmaceutical companies that make the only two medications actually approved for the treatment of fibromyalgia, which are the drug giants Pfizer with their drug Lyrica, and Eli Lilly, the maker of Cymbalta, have conducted what is known as disease mongering.
    Disease mongering is when others expand the diagnostic criteria for a particular medical issue though various ways of informing the public of the potential undetected cases of such an issue through advertising, primarily.
    Also, another method of disease mongering is though the funding of various related associations and societies through educational grants to be the voice for those who conduct disease mongering with deliberate intent to increase the profit of their medications. There is evidence to support this claim- with more funds from these companies dedicated to advertising much more than grants.
    Yet it is clear that fibromyalgia syndrome exists, as there are so many diagnosed with this medical issue that share the same symptoms, which include other symptoms besides pain alone. And it often takes a great deal of time for a patient that has fibromyalgia to receive the correct diagnosis due to the absence of any objective diagnostic testing to assess this syndrome. The fibromyalgia patient often goes through numerous other diagnostic testing, such as blood work and X-Rays, as their doctor orders such tests to rule out other diseases and disorders that may be present with the symptoms expressed with fibromyalgia syndrome.
    Variables associated with those diagnosed with fibromyalgia syndrome include those patients with a history mental illness. They also tend to be overweight and live an inactive lifestyle, overall. Also, there seems to be an association with those diagnosed with fibromyalgia and these patients being in a state of low socioeconomic status.
    Also in over 50 percent of those diagnosed with fibromyalgia, the patients are experiencing mental stress, emotional distress, as well as some sort of family conflicts as well. In fact, this stress amplifies the symptoms of fibromyalgia if these emotions are expressing themselves in the fibromyalgia patient. Insomnia is associated with fibromyalgia as well. It appears that mean age of onset of Fibromyalgia is around 40 years old, yet fibromyalgia syndrome can occur at any age.
    Aside from systemic pain of varying degrees with the fibromyalgia patient, the patient experiences affective disorders typically. Since the symptoms of fibromyalgia also could indicate other disease states in 25 percent of the patients, usually X-Rays and blood work are examined to rule out other possible causes for the symptoms.
    The Journal of the American Medical Association gave these symptoms the name of Fibromyalgia in the mid 1980s, as well as this association publically acknowledging that it is a disabling illness
    There is evidence the cause is neurological. Upon examining the spinal fluid of a fibromyalgia patient, their serotonin levels are low, which is a neurotransmitter that has multiple emotional functions, as well as elevations of the neuro-chemical protein called substance P, which is the catalyst for pain. The patients also have elevated levels of what is called nerve growth factor (NGF). NGF is a protein molecule that, when elevated, is also associated with Alzeimer’s disease, and, believe it or not, one falling in love.
    Furthermore, some fibromyalgia patents have had their brains scanned for abnormalities that may be present, and their brains in fact have shown varying degrees of structural dysfunction with their brains due to fibromyalgia.
    So some suspect not only the cause may be some sort of central nervous system injury, but also there is evidence the syndrome is from some sort of viral infection, it has been reported.
    Treatment of the fibromyalgia patient includes not only the drugs mentioned earlier, but also other medications for pain, anxiety, and insomnia in particular. Lifestyle changes are recommended for the fibromyalgia patient, as well as many other treatment methods in order to relieve their discomfort. Physical exercise is appropriately recommended for the fibromyalgia patient as well.
    What is perhaps not recommended enough is cognitive or behavioral therapy for the fibromyalgia patient. There seems to be a strong association between fibromyalgia syndrome and psychogenic or psychophysiological causes for their symptoms.
    Or, perhaps the fibromyalgia patient is suffering from some sort of guilt for some reason that is amplifies the unfortunate syndrome they are forced to tolerate.
    Mea Culpa is Latin, meaning, ‘my fault’.
    Pain is a Latin word as well. Its meaning: a fine or penalty.
    Further research, however, is needed regarding this unfortunate syndrome experienced by so many others for no solid reason defined yet.
    Dan Abshear

    Comment by Dan — February 28, 2009 #

  2. [...] Prescribing Advice for GPs » TCAs best in fibromyalgia? The Journal of the American Medical Association has published the results of a meta-analysis to determine the efficacy of antidepressants in treating the major symptoms of fibromyalgia. [...]

    Pingback by Magnetic Therapy for Fibromyalgia Trigger Points — January 21, 2009 #

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