Alphabetized List of Drugs used to

Treat Fibromyalgia Name - generic/trade, dosage FM usage Exercise Implications and Clinical Tips alosetron hydrochloride/Lotronex begin at 0.5mg bid Irritable bowel syndrome, diarrhea Exercise clients prescribed this drug may require nearby restroom facilities. If client reports bloody diarrhea, rectal pain or worsening abdominal pain, advise to discontinue med immediately, and contact HCP. alprazolam/Xanax [1] 0.25-3 mg/day Panic attacks, anxiety, early morning awakenings May increase drowsiness, dizziness. Very short half-life makes it helpful for falling back to sleep in the middle of the night without experiencing morning hangover. amitriptyline/Elavil [2] 10-100 mg at hs in single dose Mild Pain, insomnia May be hard to exercise in the AM due to morning drug ohangovero. Can produce resting tachycardia, dry mouth. Take early in the evening rather than at bedtime. zopiclone/Apo-zopiclone [3] 7.5 mg at hs Precursor to Lunesta, available from Canada for $50 for 90tablets Insomnia, unrefreshed sleep Most common side effect is a bitter or metallic taste in the mouth. Can also cause daytime drowsiness, dizziness, lightheadedness, dry mouth, headache, stomach upset. bupropion hydrochloride/Wellbutrin Slow release 150-300 mg SR bid or 300 XL qd Fatigue, fibro fog, depression May experience dizziness, dry mouth, excessive sweating, constipation. Less depression of libido than most other antidepressant medications. carbidopa, levodopa/Sinemet 10/100-20/200, 1 tab hs Restless leg syndrome, a common and frequently missed co-morbidity of FM Can cause nausea at time of dosing. Relaxation exercises may prove difficult if restless legs are not treated. carisporodol/Soma 350 mg, 1-4 times per day Muscle tension, pain, insomnia, morning stiffness Might be beneficial treatment for post-exercise pain relief. clonazepam/Klonopin, Clonapam 0.25-2 mg hs, tabs or quick dissolving wafer

Anxiety, restless leg syndrome, insomnia, unrefreshing sleep, autonomic arousal May decrease exercise motivation due to side effect of fatigue if used in the daytime. Use at night provides better rest and so can increase exercise motivation. Now being used experimentally in the daytime with elderly persons with essential tremor. cyclobenzaprine/Flexeril [4, 5,6] 5-30 mg at hs

Muscle tension, mild pain, insomnia Can cause dry mouth. Take early in the evening rather than at bedtime. Very similar in chemical structure to amitriptyline/Elavil. dextromethorphan/ Coricidin [7] Robitussin cough syrup, etc. 30-120 mg in 24 hrs Pain, weak NMDA receptor agonist. Rarely prescribed today, due to side effects. Can produce an oout-of-bodyo feeling. dicyclomine hydrochloride/Bentyl up to 20 mg oral qid





Irritable bowel syndrome (IBS)/pain Exercise clients prescribed this medication may require nearby restroom facilities. People exercising outdoors with IBS should consider walking around the block several times rather than venturing the same distance away from the house (and the restroom. J ) duloxetine hydrochloride/Cymbalta [8] 30-120 mg per day Best taken with food to prevent nausea Depression, insomnia/ unrefreshing sleep, pain Nausea possible if taken without food or close to exercise time. Adequate treatment of depression increases likelihood of initiating and maintaining an exercise program. Studies demonstrate that for most people 60mg is as effective as higher doses. eszopiclone/Lunesta 2-4 mg at hs Insomnia/unrefreshing sleep May cause increased thirst and metallic taste in mouth. ethyl chloride/Fluorimethane Spray -termed oSpray and Stretcho Dosage dependant upon body region affected and severity Muscle pain and myofascial pain syndrome (cooling and numbing facilitates stretching) Used in physical therapy to increase range of motion in areas too painful to perform adequate flexibility. Fitness professionals may wish to request this treatment for their clients, as adjunct to training program. fentanyl citrate/Actiq 200 mcq transmucosal (A Class II narcotic)

transdermal fentanyl/Duragesic Patch 72-hour patch 25 mcg/hr change q 3 days

Severe pain, including irritable bowel syndrome May impair mental ability. Causes dizziness, lightheadedness, rapid heartbeat. All opioids cause constipation and prophylactic treatment is needed. There is a potential for temperature-dependent increase in fentanyl release from the patch that could result in fentanyl overdose. Exercise clients in this degree of pain may need to avoid exercise for 3-5 days, reverting instead to flare management via medication. fludrocortisone/Florinef 0.1 mg



Adjunct to treating neurally mediated hypotension Can cause sodium retention resulting in hypertension or edema. Use gradual position changes, as clients with neurally mediated hypotension experience dizziness and are prone to falls. sodium oxybate/Xyrem [9,10] 4.5-6 mg at hs, repeating 3-4 hours later if needed

Insomnia/ unrefreshing sleep Can result in headache and nausea if taken in the daytime. May increase exercise motivation and adherence as sleep quality/quantity improves. Your provider has to order on line through a central pharmacy because this is one of the odate rapeo drugs. gabapentin/Neurontin 900-3600 mg/day in 3 divided doses or only at hs Neuropathic pain Can cause a lack of co-ordination, dizziness, nausea, daytime fatigue. Incorporate gradual position changes during exercise sessions. growth hormone/Nutropin [11] Dosage values dependent on serum Insulin like Growth Factor (IGF-1) levels and body weight. Daily sub-q injections required. Depression, fatigue, pain, quality of life May increase the chance of peripheral edema, carpal tunnel syndrome. Fitness leaders should modify movements involving weight loading at wrist joints.

hydrocodone bitartrate/Vicodin Dose needed varies with half-life of drug selected and pain level Moderate pain (one of several short acting narcotics) Medication may decrease pain if used prior to, or shortly after, an exercise session. Can cause constipation with accompanied flatulence. lidocaine/Lidocaine/Lidoderm Patch [12] Lidocaine may be directly injected in trigger points; Patch is applied directly to FM tender points Myofascial pain syndrome Avoid exercising muscles near site of tender point pain, especially if using machine weights. There may be abnormal sensation at the site of patch application. loperamide/Imodium 2-4 mg initially, up to 16 mg in 24 hours Mild IBS diarrhea prone Clients prescribed this medication may require nearby restroom facilities. lorazepam/Valium [13] 2-10mg up to qid

Sleep, anxiety, muscle relaxation, restless leg syndrome May cause dizziness, nausea, dry mouth. May increase the effects of other drugs that cause drowsiness. Very long half-life, so some prefer Clonopin instead. Incorporate gradual position changes during exercise sessions. methadone/Dolophine 5-20 mg bid Moderate to severe chronic pain Can cause dizziness, lightheadedness, nausea, constipation. Clients on this medication may need to sit if experiencing dizziness. Exercise may increase GI motility and help constipation modafinil/Provigil [14] 50-400 mg q am Severe daytime fatigue, fibro fog, circadian rhythm disruption, attention deficit disorder May cause headache, nausea, nervousness, insomnia, anxiety. A schedule IV drug, rather than schedule II like most other attention deficit medications; can be ordered in 3-month supplies or from Canada. morphine/MS Contin, Kadian 15-60 mg bid Moderate to severe chronic pain See methadone for same exercise concerns NSAIDs*/Advil, Nuprin, Aleve [15] Dose depends on agent chosen

*Non-steroidal Anti-inflammatory agents Chronic headaches, tendonitis, concurrent osteoarthritis Taken 1 hour before exercise, can relieve peripheral pain. Note that these medications provide minimal relief of centralized FM pain, since they generally decrease only peripheral pain. May cause mild nausea, indigestion, heartburn. oxycodone/Percocet, Percodan Dosage varies with half-life of drug selected and pain level Moderate Pain See methadone for same exercise concerns. oxycodone hydrochloride /Oxycontin 10-30 mg bid Moderate to severe chronic pain See methadone for same exercise concerns. pindolol /Visken 7.5-15.0 mg / day

Pain Lowered blood pressure reading. Side effects may include fatigue, weakness, dizziness. May require modifications limiting quick position changes because of dizziness. Old, inexpensive medication newly tested in FM. pramipexole dihydrochloride/ Mirapex [16] 0.125-1.5 mg at dinnertime

Restless leg syndrome; some report using 4mg for overall FM symptom relief May cause drowsiness, dizziness, nausea, constipation. Cue exercise client to rise slowly and use caution to prevent a fall. New users may experience a drop in blood pressure. pregabalin/Lyrica [17] 450 mg divided bid or only at bedtime if causes daytime fatigue



Fatigue, pain (both deep and superficial), insomnia May cause dizziness, sleepiness, poor co-ordination, difficulty with vision, dry mouth, tremor. Cue client to rise slowly and use caution to prevent a fall. Use at night provides better rest and so can increase exercise motivation. pyridostigmine bromide/Mestinon [18] 60 mg-180 mg time span bid

Normalize growth hormone response to exercise, decrease anxiety, fatigue, enhance sleep May increase ability to exercise with less post-exertional pain and fatigue. Side effects may include nausea, diarrhea, abdominal cramps, muscle cramps/twitching, weakness. SSRIs* Those tested in FM include: Fluoxetine/Prozac, Sarafem [20] citalopram hydrobromide/Celexa [21] sertraline hydrochloride/ Zoloft [22] Dosage depends on agent chosen

* Selective Serotonin Reuptake Inhibitors Depression; +/- Anxiety Can cause nausea, insomnia, irritability, decreased libido, rebound depression. Adequate treatment of depression increases likelihood of initiating and maintaining an exercise program.

tegaserod maleate/ Zelnorm 6 mg bid before breakfast and 2 hours after dinner, on empty stomach

Irritable bowel syndrome, constipation type; works on brain-gut serotonin connection, unlike laxatives May cause diarrhea, headache (including migraine), back or joint pain, nausea, flatulence. tinzanidine hydrochloride/Zanaflex [23] 2-12 mg hs

Muscle relaxation, mild pain, sleep, morning stiffness May cause drowsiness, dizziness, weakness, dry mouth, spasms, sweating. Cue exercise clients to rise slowly and use caution to prevent a fall. topiramate/Topamax 25-100mg Migraine prevention May cause dizziness, drowsiness, peripheral neuropathy, loss of appetite. Decreased sweating and high body temperature have been associated with use. Additional fluid may be necessary during hot weather or vigorous exercise. Cue exercise clients to rise slowly and use caution to prevent a fall. Avoid overexertion during cardio-aerobic exercise. tramadol hydrochloride with acetaminophen/Ultracet [24] 37.5 mg every 4-8 hours not to exceed 8 in 24 hours Mild to Moderate Pain

May cause dizziness, drowsiness, nausea. Cue clients to rise slowly and use caution to prevent a fall. Useful for post-exertion pain or immediately prior to exercise. tramadol hydrochloride/Ultram [25] 50-100 mg every 4-8 hs, not to exceed 400 mg in 24 hours

Mild to Moderate Pain May cause dizziness, drowsiness, nausea. Cue clients to rise slowly and use caution to prevent a fall. Useful for post-exertion pain or immediately prior to exercise. trazadone Hydrochloride/Desyrel, Trazon, Trialodine [22] 50-150 mg/day hs Depression, sleep Very long drug half-life may make morning exercise more difficult. zolpidem/Ambien [26] -10 mg hs or Ambien CR 12.5mg at hs Sleep May cause dizziness, nightmares, overnight memory loss. Cue exercise clients to rise slowly and use caution to prevent a fall. Use at night provides better rest, increasing exercise motivation. zonisamide/Zonegran 100-400 mg q hs only to minimize side effects of fatigue and dizziness when taken in the daytime Neuropathic pain May cause mild drowsiness, dizziness, decreased concentration, vision problems, poor coordination. Cue exercise clients to rise slowly and use caution to prevent a fall. Remind clients to drink 6 to 8 glasses of water a day to help prevent the formation of kidney stones.

o2006 Jones K.D., Hoffman J.H.- Table: Alphabetized List of Drugs often used for the Treatment of Fibromyalgia Symptoms

References: White KP, Nielson WR: Cognitive behavioral treatment of fibromyalgia syndrome: A follow-up assessment. The Journal of Rheumatology 1995, 22(4):717-721. Goldenberg DL, Burckhardt C, Crofford L: Management of fibromyalgia syndrome. Jama 2004, 292(19):2388-2395. Drewes A, Andreasen, A, Jennum, P, Nielsen, KD: Zopiclone in the treatment of sleep abnormalities in fibromyalgia. Scand J Rheumatol 1991, 20(4):288-293. Carette S, McCain GA, Bell DA, al. e: Evaluation of amitriptyline in primary fibrositis: a double blind, placebo-controlled study. Arthritis and Rheumatism 1986, 29:655-659. Carette S, Bell MJ, Reyonolds WJ, al. e: Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia. Arthritis and Rheumatism 1994, 37 (1):32-40. Reynolds WJ, Moldofsky H, Saskin P: The effects of cyclobenzaprine on sleep physiology and symptoms in patients with fibromyalgia. Journal of Rheumatology 1991, 18:452-454. Clark SR BR: Supplemental dextromethorphan in the treatment of fibromyalgia: a double-blind, placebo-controlled study of efficacy and side-effects. Arth Rheum 2000, 43(S333). Arnold LM, Lu Y, Crofford LJ, Wohlreich M, Detke MJ, Iyengar S, Goldstein DJ: A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis and Rheumatism 2004, 50(9):2974-2984. Russell IJ, Bennett, R.M.,Michalek, J.E.: Sodium Oxybate Relieves Pain and Improves Sleep in Fibromyalgia Syndrome [FMS]: A Randomized, Double-Blind, Placebo-Controlled, Multi-Center Clinical Trial. American College of Rheumatology, Late Breaking Abstracts 2005. Scharf MB, Baumann M, Berkowitz DV: The effects of sodium oxybate on clinical symptoms and sleep patterns in patients with fibromyalgia. J Rheumatol 2003, 30(5):1070-1074. Bennett RM, Clark SC, Walcyzk J: A randomized, double-blind, placebo-controlled study of growth hormone in the treatment of fibromyalgia. The American Journal of Medicine 1998, 104:227-231. Hong CZ: Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994, 73(4):256-263. Holman AJ: Safety and efficacy of lorazepam for fibromyalgia after one year. Arthritis & Rheum 1999, 42(9):S152. Disdier P, Genton P, Milandre C, Bernard PM, Millet Y: Fibrositis syndrome and narcolepsy. J Rheumatol 1993, 20(5):888-889. Russell IJ, Fletcher EM, Michalek JE, McBroom PC, Hester GG: Treatment of primary fibrositis/fibromyalgia syndrome with ibuprofen and alprazolam. A double-blind, placebo-controlled study. Arthritis Rheum 1991, 34(5):552-560. Holman AJ, Myers RR: A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis and Rheumatism 2005, 52(8):2495-2505. Crofford LJ, Rowbotham MC, Mease PJ, Russell IJ, Dworkin RH, Corbin AE, Young JP, Jr., LaMoreaux LK, Martin SA, Sharma U: Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis and Rheumatism 2005, 52(4):1264-1273. ones KD, Burckhardt, C.S., Deodhar, A.A., Nancy, A., Hanson, G., Bennett, R.M.: Pyridostigmine normalizes growth hormone response to acute exercise in fibromyalgia patients, but is not superior to exercise for symptom control. Arthritis and Rheumatism 2005, 52(9):S267. Holman AJ: Ropinole, Open Preliminary Observations of a Dopamine Agonist for Refractory Fibromyalgia. Journal of Clinical Rheumatology 2003, 9(4):82. Arnold LM, Hess EV, Hudson JI, Welge JA, Berno SE, Keck PE, Jr.: A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Am J Med 2002, 112(3):191-197. Anderberg UM, Marteinsdottir I, von Knorring L: Citalopram in patients with fibromyalgia--a randomized, double-blind, placebo-controlled study. Eur J Pain 2000, 4(1):27-35. Miller LJ, Kubes KL: Serotonergic agents in the treatment of fibromyalgia syndrome. Ann Pharmacotherapy 2002, 36(4):707-712. Russell IJ: Therapy with a central alpha-2-adrengeric agonis [tinzanidine] decreases cerebrospinal fluid substance P, and my reduce serum hyaluronic acid as it improves the clinical symptoms of the fibromyalgia syndrome. Arthritis and Rheumatism 2002, 46 (supplement 9):S614. Bennett RM, Kamin M, Karim R, Rosenthal N: Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. Am J Med 2003, 114(7):537-545. Russel IJ, Bennett, R.M., Katz, W.R., Kamin, M.: Efficacy of Ultram (Tramadol HCL) in the treatment of fibromyalgia syndrome: Preliminary analysis of a randomized, placebo-controlled study. Journal of Clinical Rheumatology 2000, 6:250-257 Moldofsky H, Lue FA, Mously C, Roth-Schechter B, Reynolds WJ: The effect of zolpidem in patients with fibromyalgia: a dose ranging, double blind, placebo controlled, modified crossover study. J Rheumatology 1996, 23(3):529-533.