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208 Fibromyalgia
n Summary and recommendations
First line:
n cyclobenzaprine (10 mg PO TID) or
n tramadol (25 mg PO daily, titrated up to 25 mg four times daily) plus
acetaminophen (1000 mg q 6 h)
Reasonable:
n amitriptyline (25–50 mg PO QD)
n pregabalin (150 mg/day PO divided BID–TID; may increase to 450 mg/day
PO divided BID–TID)
n pramipexole (0.125 mg PO TID)
n alprazolam (0.5 mg PO QD)
Pregnancy: ondansetron (4 mg PO QD–TID)
Pediatric:
n ondansetron (4 mg PO TID; lower doses if age < 4 years)
n low-dose TCA such as amitriptyline (1 mg/kg PO divided TID has been
recommended but there is limited supporting evidence; particular caution
is warranted in patients under 12 years)
n local anesthetic injection
Special cases:
n patient with refractory pain and no non-opioid options: trial of IV opioids (e.g.
morphine initial dose 4–6 mg IV, then titrate) with outpatient opioids (e.g.
oxycodone 5–10 mg PO q4–6 h) prescribed if there is response to IV therapy
n patients already on therapy: most patients have tried (many) therapeutic
approaches before presenting to acute care providers; in many cases, the
drugs patients are already taking may be dose escalated to the maxima
outlined in this chapter
n patients starting on a new drug: optimal fibromyalgia patient care requires
a long-term plan; acute care providers instituting a new agent can, in
consultation with follow-up providers where possible, plan for dose escalation
of new agents (e.g. tramadol, pregabalin) for which the initial dose is
much lower than the maximum (and more effective) dose