New and emerging therapeutic agents for the treatment of fibromyalgia: an update

Figures & data

Table 1 Examples of standard, new, and emerging therapeutic options for the treatment of fibromyalgia

Pharmacologic treatment	Type	Class	Molecular mechanism(s)	APS 2005^Citation22	EULAR 2007^Citation23	Approval status
Standard treatments
NSAIDs (eg, aspirin, naproxen, ibuprofen)	N/A	Selective or nonselective	COX^b-1,2 inhibition; COX^b-2 inhibition	NE	NE	Not approved
Opioids (eg, morphine, codeine, fentanyl, nalbuphine)	Scheduled or nonscheduled	Agonist, partial agonist, agonist-antagonist, or antagonist	Mu-, kappa-, delta-opioid receptor binding	NE	NE	Not approved
Tramadol	Nonscheduled opioid analgesic; adjuvant analgesic (antidepressant)	Agonist; SNRI	Mu-opioid receptor binding; norepinephrine/serotonin reuptake inhibition	ME	SE	Not approved
Amitriptyline	Adjuvant analgesic (antidepressant)	TCA	Na^+ ion channel inhibition; NMDA receptor blockade (non-neuroprotective)	SE	SE	Not approved
Fluoxetine	Adjuvant analgesic (antidepressant)	SSRI	Serotonin reuptake inhibition	ME	SE	Not approved
Gabapentin	Adjuvant analgesic (anticonvulsant)	N/A	VGCC alpha-2-delta subunit binding	N/A	N/A	Not approved
S-adenosylmethionine	Adjuvant analgesic (antidepressant)	N/A	Nervous system methylation	WE	N/A	Not approved
Cyclobenzaprine	Skeletal muscle relaxant	N/A	5-HT2 receptor antagonist	SE	N/A	Not approved
Growth hormone	N/A	Hormone	Numerous	WE	N/A	Not approved
New treatments
Pregabalin	Adjuvant analgesic (anticonvulsant)	N/A	VGCC alpha-2-delta subunit binding	ME	SE	FDA-approved (2007)
Duloxetine	Adjuvant analgesic (antidepressant)	SNRI	Serotonin/norepinephrine reuptake inhibition	ME	SE	FDA-approved (2008)
Milnacipran	Adjuvant analgesic (antidepressant)	SNRI	Serotonin/norepinephrine reuptake inhibition	ME	SE	FDA-approved (2009)
Emerging treatments
Pramipexole	Adjuvant analgesic	Agonist	Selective non-ergoline D2, D3, and D4 dopamine receptor binding	N/A	SE	Not approved
Dextromethorphan	Adjuvant analgesic	Antagonist	NMDAR	N/A	N/A	Not approved
Ketamine	Adjuvant analgesic	Antagonist	NMDAR	N/A	N/A	Not approved
Sodium oxybate	Adjuvant analgesic	Central nervous system depressant	GABAB and GHB receptors (proposed)	N/A	N/A	Not approved
Low-dose naltrexone	Opiate analgesia enhancer	Opioid antagonist	Disruption of mu-opioid receptor Gs coupling via filamin A binding	N/A	N/A	Not approved
Delta-9-THC	Adjuvant analgesic	Psychoactive cannabinoid	Numerous	N/A	N/A	Not approved

Abbreviations: APS, American Pain Society; COX, cyclooxygenase; EULAR, European League Against Rheumatism; FDA, Food and Drug Administration; FM, fibromyalgia; ME, modest efficacy; NA, not applicable; NE, no evidence of efficacy; NMDAR, N-methyl D-aspartate receptor; NSAID, nonsteroidal anti-inflammatory drug; SE, strong efficacy; SNRI, serotonin/norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; VGCC, voltage-gated calcium ion channel; WE, weak efficacy.

American Pain SocietyGuidelines for the management of fibromyalgia syndrome pain in adults and children Available from: http://www.ampainsoc.org/pub/fibromyalgia.htm. 2005. Accessed Dec 2, 2009.

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