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#381 Pharm for Fibro, Round 2: Can gabapentinoids ease the pain?


CLINICAL QUESTION
QUESTION CLINIQUE
Do gabapentinoids reduce pain in patients with fibromyalgia?


BOTTOM LINE
RÉSULTAT FINAL
About 40% of people with fibromyalgia on pregabalin 300-600mg/day experience a meaningful reduction in pain (pain reduced by ≥30%) versus 30% on placebo at 8-14 weeks.  Lower doses (example: 150mg) may not be effective; however, higher doses cause more harm, with up to ~30% of people stopping due to side effects (versus 10% on placebo). Based on one small randomized, controlled trial (RCT), gabapentin is also effective.



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EVIDENCE
DONNÉES PROBANTES
  • Statistically significant unless indicated.
  • Pregabalin versus placebo: 1 systematic review (5 RCTs, 3283 patients, 150-600mg daily). At 8-14 weeks:1
    • Proportion of patients with ≥30% reduction in pain:
      • 150mg: no difference.
      • 300-600mg: 39-43% versus 29% (placebo), Number Needed to Treat (NNT)~8-10.
    • Adverse event withdrawals:
      • 150mg: no difference.
      • 300-600mg: 17-28% versus 10% (placebo), Number Needed to Harm (NNH)=6-15.
      • Some adverse effects increased with higher doses. Examples:
        • Dizziness: 32% (300mg) versus 46% (600mg) versus 10% (placebo), NNH~3-5.
        • Peripheral edema: 6.5% (300mg) versus 11% (600mg) versus ~2% (placebo) NNH=11-23.
  • Pregabalin 150mg versus duloxetine 60mg: One RCT, 66 patients. At 4 weeks:2
    • Number of pain sites (up to 19 possible sites, baseline~8): reduced to 6.3 (pregabalin) versus 4 (duloxetine).
  • Pregabalin (300-450mg) added to antidepressants: One RCT, 181 patients on various anti-depressants. At 6 weeks:3
    • Proportion with ≥30% pain reduction: 45% (pregabalin add-on) versus 28% (no add-on), NNT=6.
  • Gabapentin: 1 publicly funded RCT, 150 patients, 1200-2400mg/day. After 12 weeks:4
    • Proportion with ≥30% pain reduction: 51% versus 31% (placebo), NNT=5.
    • Global improvement: 68% versus 35% (placebo), NNT=3.
    • Adverse events:
      • Withdrawal due to adverse events: No difference.
      • Sedation: 24% versus 4% (placebo); dizziness 25% versus 9% (placebo). NNH=5-7.
  • Limitations: All pregabalin studies were industry funded. Most studies excluded patients on antidepressants.

CONTEXT
CONTEXTE
  • Canadian guidelines: Antidepressant medications can be used based on individual presentation and anticonvulsants can be tried, up-titrating as tolerated.5
  • Depression is present in about 22% patients with fibromyalgia.6
  • Duloxetine and mirtazapine reduce pain by ≥30% in ~50% of patients with fibromyalgia versus 35% placebo.7
  • 90-day costs:8 pregabalin 300mg ~$95; gabapentin 900mg ~$45.


Ken Jaskolka January 20, 2025

Will consider using higher doses of Pregabalin in the appropriate situation.

Kevin Black January 20, 2025

Helpful information.


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#381 Pharm for Fibro, Round 2: Can gabapentinoids ease the pain?

Do gabapentinoids reduce pain in patients with fibromyalgia?
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Author(s)
Auteur(s)
  • Jennifer Young MD CCFP-EM
  • Anneke Froentjes BSc (Medical student)
  • Betsy Thomas BSc. Pharm
  • Danielle Perry RN MSc

1. Derry S, Cording M, Wiffen PJ et al. Cochrane Database Syst Rev. 2016 Sep 29;9(9):CD011790.

2. Bidari A, Moazen-Zadeh E, Ghavidel-Parsa et al. DARU J Pharm Sci. 2019 Jun;27(1):149-158.

3. Arnold LM, Sarzi-Puttini P, Arsenault P et al. J Rheumatol. 2015 Jul;42(7):1237-44.

4. Arnold LM, Goldenberg DL, Stanford SB et al. Arthritis Rheum. 2007 Apr;56(4):1336-44.

5. Fitzcharles MA, Ste-Marie PA, Goldenberg DL et al. Pain Res Manag. 2013 May-Jun;18(3):119-26.

6. Fuller-Thomson E, Nimigon-Young J, Brennenstuhl S. Rheumatol Int. 2012 Apr;32(4):853-62.

7. Young J, Perry D, Thomas B. Tools for Practice #375: Pharm for Fibro: Can antidepressants ease the pain? Available at https://cfpclearn.ca/tfp375/. Accessed October 18, 2024.

8. Personal communication with Shraddha Joshi at Summerside Pharmacy, Edmonton, Alberta, August 1, 2024.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.