Pearls of Wisdom: Options for Management of Fibromyalgia

Madison is a 36-year-old, divorced, obese woman with migraine and fibromyalgia. Her adherence to exercise recommendations has been poor. Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), anxiolytics, and pregabalin have failed. She is now asking for opioid analgesia.

You might try:

A) Oxycodone, 5 mg, plus acetaminophen, 325 mg, 4 times a day
B) Tramadol, 50 mg 4 times a day
C) Cyclobenzaprine, 10 mg 3 times a day
D) Memantine, 20 mg daily

What is the correct answer?

(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.

Answer: Memantine 20 mg daily

The Research

In a randomized, double-blind, controlled trial discussing the use of memantine that followed the cases of 63 patients for 6 months, the authors reported that memantine has been used successfully off-label in the past for the treatment of Parkinson spasticity, vascular dementia, Alzheimer disease, and even phantom limb pain.

Memantine was administered at 5 mg/d for the first week, then 10 mg/d in week 2, 15 mg/d in week 3, and 20 mg/d from week 4 to week 21.

The Results

Primary outcomes were pain and anxiety at 6 months. Overall, pain, pain threshold, cognitive function, and depression were all favorably affected, and adverse events were “mild and infrequent.”

What’s the “Take-Home”?

Exercise is the only consistently effective management tool for fibromyalgia. Duloxetine, milnacipran, and pregabalin are all approved by the US Food and Drug Administration for fibromyalgia, but their efficacy is less than perfect, and sometimes patients reject taking medications indicated for anxiety or depression, concerned that we do not consider their symptoms to be “real” but rather secondary to anxiety or depression.

It is nice to have a medication that patients might use beneficially, that does not have any association with mood disorders, and that still might provide meaningful improvement without risks for dependency, abuse, or addiction. While it is probably not a first-line option, we may at least have a potential tool for the management of fibromyalgia in memantine.

Reference:

Olivan-Blázquez B, Herrera-Mercadal P, Puebla-Guedea M, et al. Efficacy of memantine in the treatment of fibromyalgia: a double‐blind, randomised, controlled trial with 6‐month follow-up. Pain. 2014;155(12):2517-2525.