The older antidepressants (or as I prefer to call them “neurotransmitter boosters”) can be very effective in helping with pain and sleep as this article originally published in the Journal of the AMA (JAMA) reveals. They are inexpensive (all generic). They should be started in very low doses.
Too many patients I have seen were placed an the amount used for depression which is way too high for us “FMSers” I have found starting with 10 mg of amitriptylline (Elavil) or nortryptalline at bedtime to be a good starting dose. Even if you are on one of the newer SSRIs or SNRIs you could ask your doctor about adding a low dose of one of these “tricyclics” at bedtime.

NOTE THAT THIS STUDY FOUND THEM MORE EFFECTIVE THAN THE NEWER ANTIDEPRESSANTS IN SEVERAL WAYS. OF COURSE, ALWAYS ASK YOUR PHYSICIAN BEFORE MAKING ANY CHANGES.

yours, Dr. Don

(By Linda Searing

THE WASHINGTON POST

Published: March 5, 2009

The question: Might antidepressants help relieve the pain, sleep problems and other symptoms that afflict people with fibromyalgia?

This study: It analyzed data from 18 studies, involving 1,427 people with fibromyalgia, mostly women, who had been randomly assigned to take an antidepressant or a placebo for up to about two years. At the end of the studies, people who took antidepressants reported, on average, less pain, fewer sleep problems, less depression and an improving quality of life compared with those who took a placebo. Generally, conventional antidepressants — tricyclic and tetracyclic drugs, sometimes called typical antidepressants — were deemed more successful in pain relief than were SSRIs (selective serotonin reuptake inhibitors) and other second-generation, or atypical, antidepressants. ( read Cymbalta, Savella )

Who may be affected? People with fibromyalgia, a disorder characterized by widespread pain and tenderness as well as fatigue. It is more common in women than in men. Medication can help relieve symptoms, but no cure for the condition has been found.

Caveats: Most data came from the participants’ assessments of symptoms. The studies did not include data on other illnesses participants might have had or on other treatments or medications they might have taken. Only one antidepressant used in the studies, duloxetine (Cymbalta), has been approved by the Food and Drug Administration to treat fibromyalgia.

Find this study: Jan. 14 issue of the Journal of the American Medical Association.

“Pristiq” is the latest in the group of anti-depressants known as SNRIs, or serotonin and norepinephrine reuptake inhibitors. Also in this class is Cymbalta (duloxetine), which is the only anti-depressant that has an FDA approval for fibromyalgia. “Venlafaxine” (Effexor, Effexor XR) is another SNRI and is quite similar to Pristiq which is the trade name for “desvenlafaxine.
I suspect we will be hearing more about Pristiq because it is so similar to Effexor and Cymbalta. I began prescribing Effexor for FMS and pain patients several years ago because it seemed to work better on their depression/pain overlap than the SSRIs which are “selective serotonin reuptake inhibitors”. Examples of SSRIs are Paxil, Zoloft, Celexa, and many others.

This is called “off-label” prescribing by the FDA and simply means that the physician is prescribing a medication for something the FDA has not approved it for. It is entirely accepted and legal and is done with all kind of medications we know can help a particular problem but has not gone through the arduous FDA process.

We know that the neurotransmitters serotonin and norepinephrine seem to be involved in FMS (see “What causes Fibromyalgia”), CFS, and other chronic pain syndromes. Therefore a medication that boosts the levels of these could potentially be helpful.

My concern with Pristiq is that it is not very flexible in it’s dosing at this time. Those of us with FMS and related disorders can be unusually sensitive to medications. My axiom is to “start low and go slow.”
Start with a very low dose and gradually increase the dose if until there is a response.
On the other hand the fact that it is sustained-release is a plus. This allows for once/daily dosing and more constant drug levels.
This does not mean to try Pristiq if your physician recommends it. It may work great for you. I suspect, however, that a lower dosage form of Pristiq will be needed if it is to become helpful in our quest.

Yours, Dr. Don

P.S. If any of you have tried or are on Pristiq I would love to hear from you in the comments section or by email!!!