AboutDr Alan Galbraith Expertise I can answer most questions on most drugs. Answers can be given in either technical or layperson terminology. My main areas of interest are psychiatric, gastrointestinal and cardiovascular drugs.
Experience I have been a university lecturer/head of department for almost thirty years, but am now retired. My research interests were alcohol, smoking and cardiovascular disease.
Organizations Institute of Biology, London.
Publications Author of "Fundamentals of Pharmacology" 5th Edition published in November 2007 by Pearson Education, Australia.
Question -------------------------
Followup To
Question -
Hi :)
Any new drugs that work well for fibromyalgia?
Thank you
Marianne
Answer -
Dear Marianne
Apologies for the delay but allexperts.com have been having pronblems with their server and although I could see your question I could not send my reply. I hate being in this position as a pride myself in responses in answering no longer than 12 hours after the question was posed.
Tell me what drugs you know and I'll give you an update if required.
Regards
Dr Alan Galbraith
Only 1-diclofen 75mg taken at this time Marianne
Answer Dear Marianne
I have attached a complete list of possibilities. Diclofen belongs to the first box ie analgesics/NSAIDS.
Some of this may be a bit technical for you but get back if you want clarification on any point. It is rather long but you should find out what you want to know from this.
Drug Category: Analgesics -- Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are usually of limited efficacy. Severe allodynia may require tramadol or opioid analgesics. Opioids bind opioid receptors in regions of the brain involved in integrating pain and to presynaptic and postsynaptic terminals of peripheral sensory fibers where they inhibit the release of substance P and other mediators. Older persons are more sensitive to opioids with respect to both efficacy for pain relief and vulnerability to adverse effects; therefore, the starting dose should be reduced 25-50%. Expect several weeks or months for titration after initiating opioid therapy in the outpatient setting. Tapering takes 2-3 weeks; clonidine, 0.2-0.4 mg/d, is helpful for controlling withdrawal symptoms.
Monitoring of patients taking analgesic medications requires frequent reevaluation for efficacy and adverse effects during initiation, titration, and maintenance therapy.Drug Name
Acetaminophen (Tylenol, Feverall, Tempra, Aspirin-Free Anacin) -- DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper gastrointestinal disease, or those taking oral anticoagulants.
Adult Dose 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Contraindications Documented hypersensitivity
Interactions Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
Drug Name
Tramadol (Ultram) -- Inhibits ascending pain pathways, altering perception of and response to pain. Inhibits reuptake of norepinephrine and serotonin.
Adult Dose 50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOIs
Interactions Significantly decreases carbamazepine effects; cimetidine increases toxicity; risk of serotonin syndrome with coadministration of antidepressants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Can cause dizziness, nausea, constipation, sweating, and pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, and hypoadrenalism; caution in pregnancy or breastfeeding; caution in patients with seizures; development of tolerance or dependency with extended use; inhibits reuptake of norepinephrine and serotonin; adverse effects include constipation, nausea and vomiting, sedation, cognitive impairment, miosis, myoclonus, urinary retention, and respiratory depression (most dangerous, reverse with naloxone)
Drug Name
Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab) -- Can be used with precaution and an agreement to undergo counseling in patients with severe allodynia.
Adult Dose 1-2 tab or cap PO q4-6h prn for pain
Pediatric Dose <12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate/dose or 5 doses/24 h
Contraindications Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Interactions Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Drug Category: Anxiolytics/hypnotics -- Agents of varying durations of action are used frequently for anxiety and panic and as sleep aids (poor sleep is nearly universal in FM). These agents also have antinociceptive effects in patients with chronic pain. Anxiolytics sometimes are used in combination with antidepressants and antiepileptic drugs. Benzodiazepines (eg, alprazolam, lorazepam, clonazepam), buspirone (BuSpar), trazodone (Desyrel), zolpidem (Ambien), and others in the anticholinergic and antihistaminergic classes are useful. With respect to treatment of insomnia, do not forget to suggest optimum sleep hygiene.Drug Name
Alprazolam (Xanax) -- Binds receptors at several sites within the CNS, including the limbic system and reticular formation. Effects may be mediated through GABA receptor system. Short half-life (<12 h).
Adult Dose 0.25-0.5 mg PO tid; average effective dose is 0.5-4 mg/d PO
Pediatric Dose Not established
Contraindications Documented hypersensitivity; severe respiratory depression; narrow-angle glaucoma; preexisting hypotension
Interactions Carbamazepine and disulfiram decrease effects; toxicity increases with cimetidine, lithium, contraceptives, and CNS depressants (including alcohol)
Pregnancy D - Unsafe in pregnancy
Precautions Withdrawal symptoms, including seizures, may occur upon abrupt discontinuation
Drug Name
Lorazepam (Ativan) -- Sedative hypnotic with short onset of action and relatively long half-life (10-15 h). By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Excellent when patient needs to be sedated for >24 h.
Adult Dose 1-10 mg/d PO divided bid/tid
Pediatric Dose 0.05 mg/kg/dose PO q4-8h
Contraindications Documented hypersensitivity; preexisting CNS depression, hypotension, and narrow-angle glaucoma
Interactions CNS toxicity of benzodiazepines increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Pregnancy D - Unsafe in pregnancy
Precautions Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Drug Name
Clonazepam (Klonopin) -- Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters. Long half-life (25-100 h).
Adult Dose Initial: 1.5 mg PO divided tid
Maintenance: Increase dose by 0.5-1 mg PO q3d to 0.05-0.2 mg/kg in divided doses; not to exceed 20 mg/d
Pediatric Dose <10 years: 0.01-0.03 mg/kg/d PO bid/tid; increase dose by 0.5 mg q3d to 0.1-0.2 mg/kg/d divided tid; not to exceed 0.2 mg/kg/d
>10 years: Administer as in adults
Contraindications Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma
Interactions Phenytoin and barbiturates may reduce effects; coadministration of CNS depressants increases toxicity
Pregnancy D - Unsafe in pregnancy
Precautions Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation
Drug Name
Zolpidem (Ambien) -- Indicated for insomnia. Structurally dissimilar to benzodiazepines but similar in activity, with the exception of having reduced effects on skeletal muscle and seizure threshold.
Adult Dose 10 mg PO hs; not to exceed 10 mg
Pediatric Dose Not established
Contraindications Documented hypersensitivity; lactation
Interactions Increases toxicity of alcohol and CNS depressants
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Monitor elderly patients for impaired cognitive or motor performance
Drug Name
Trazodone (Desyrel) -- Useful as an alternative to improve sleep and to treat anxiety and panic disorders that may be associated with FM. Antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. Also has negligible affinity for cholinergic and histaminergic receptors. In animals, selectively inhibits serotonin uptake by brain synaptosomes and potentiates behavioral changes induced by serotonin precursor, 5-hydroxytryptophan.
Adult Dose Initial: 150 mg/d PO and may increase by 50 mg/d q3-4d; not to exceed 400 mg/d in divided doses; average dose is 300 mg/d
Maintenance: Once an adequate response has been achieved, dosage may be reduced gradually with subsequent adjustment depending on response; keep dose at the lowest effective level
Pediatric Dose <6 years: Not established
6-18 years: 1.5-2 mg/kg/d PO in divided doses; increase dose gradually q3-4d prn; not to exceed 6 mg/kg/d
Contraindications Documented hypersensitivity
Interactions May enhance response to alcohol, barbiturates, and other CNS depressants; digoxin and phenytoin serum levels may increase in patients receiving trazodone concurrently; may decrease hypoprothrombinemic effects of warfarin
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Hypotension, including orthostatic hypotension and syncope, has occurred; may produce drowsiness, dizziness, or blurred vision; patients should observe caution while driving or performing other tasks requiring alertness, coordination, or dexterity
Drug Name
Buspirone (BuSpar) -- 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take as long as 2-3 wk for full efficacy.
Adult Dose 15 mg/d PO divided tid; increase by 5 mg/d q2-4d; not to exceed 60 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Toxicity is increased with MAOIs, phenothiazines, and CNS depressants; increases toxicity of digoxin and haloperidol
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in hepatic or renal impairment
Drug Name
Temazepam (Restoril) -- Indicated for insomnia. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Adult Dose 15-30 mg PO hs; start with 15 mg PO hs in elderly or debilitated patients
Pediatric Dose Not established
Contraindications Documented hypersensitivity; narrow-angle glaucoma; untreated obstructive sleep apnea; history of substance abuse; severe uncontrolled pain
Interactions Increases CNS toxicity of benzodiazepines with coadministration of phenothiazines, barbiturates, alcohol, and MAOIs
Pregnancy X - Contraindicated in pregnancy
Precautions Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Drug Category: Skeletal muscle relaxants -- Have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established. Sedation and other CNS effects occur frequently. Abuse may occur, particularly with carisoprodol, and abrupt cessation may be associated with withdrawal symptoms.Drug Name
Cyclobenzaprine (Flexeril) -- Acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to TCAs and, thus, carries some of the same liabilities.
Adult Dose 20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d; increase at rate of 10 mg/d at weekly intervals
Pediatric Dose Not established
Contraindications Documented hypersensitivity; MAOIs within last 14 d
Interactions Coadministration with MAOIs and TCAs may increase toxicity; cyclobenzaprine may have additive effects when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Angle-closure glaucoma; urinary hesitance
Drug Name
Carisoprodol (Soma) -- Short-acting medication that may have depressant effects at spinal cord level.
Adult Dose 350 mg PO tid/qid
Pediatric Dose Not established
Contraindications Documented hypersensitivity; acute intermittent porphyria; addictive behavior
Interactions Increases toxicity of alcohol, CNS depressants, MAOIs, clindamycin, and phenothiazines
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in renal and hepatic impairment; caution in patients with potential for addiction
Drug Category: Antidepressants -- Low-dose TCAs are of proven short-term efficacy for pain control and improved sleep in patients with FM, but adverse effects (eg, dry mouth, drowsiness, weight gain) limit patient acceptance. SSRIs and the large number of other antidepressants with different mechanisms of action are not effective substitutes for TCAs as analgesic agents but should be used for the frequently concomitant depression that amplifies pain.Drug Name
Amitriptyline (Elavil) -- Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS.
Adult Dose Initial: 10 mg PO hs, with slow 10-mg escalation weekly to 70-80 mg hs
Pediatric Dose Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses
Contraindications Documented hypersensitivity; MAOIs in past 14 d; glaucoma and urinary retention
Interactions Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Pregnancy D - Unsafe in pregnancy
Precautions Caution in cardiac conduction disturbances, history of seizures, history of hyperthyroidism, and renal or hepatic impairment; avoid in elderly patients
Drug Category: Anticonvulsants -- Useful for chronic pain states, including FM and related syndromes and various types of neuropathic pain. Gabapentin also may ameliorate associated depressed mood and anxiety. Doses as high as 3600 mg/d in divided doses may be used with few adverse effects. Other newer GABA analogs are also promising.Drug Name
Gabapentin (Neurontin) -- Effective for pain and associated depressed mood and anxiety. Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA but does not interact with GABA receptors. Titration to effect can take place over several days to weeks.
Adult Dose Day 1: 300 mg PO qd
Day 2: 300 mg PO bid
Day 3: 300 mg tid and titrate prn; not to exceed 1200 mg PO qid
Pediatric Dose <12 years: Not established
>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may increase norethindrone levels significantly
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in severe renal disease
