A new review of research into the use of amitriptyline as a treatment for fibromyalgia finds it to be effective only in the short-term and in low doses.

Amitriptyline is an older generation antidepressant drug of the tricyclic family and is often recommended and prescribed for the treatment of the symptoms of fibromyalgia.

Due to its sedative effects amitriptyline is used to help patients with sleep and to reduce the associated symptoms of pain and fatigue. Patients, doctors and researchers generally agree that adequate duration and quality of sleep is essential to improve the patient's overall condition (see: Restorative sleep predicts the resolution of chronic widespread pain).

According to a new review of studies published in respected medical journals however amitriptyline is only a moderately effective treatment for fibromyalgia.

Researchers looked at studies in the PubMed, EMBASE and Cochrane Library medical research indexes and found ten randomized controlled trials (RCTs) which met their criteria and were of sufficient size and quality. RCTs are medical studies where a drug (or other intervention) is compared to a placebo in the treatment of a particular condition.

The researchers looked at six RCTs that used a dose of 25 mg/day of the drug. They found that compared to a placebo this helped patients' with their symptoms of pain, sleep, fatigue and both patients' and their doctors overall impression of their health.

Strangely the benefit was seen in trials lasting 6-8 weeks but in a trial that lasted 12 weeks no effect was seen. It must be noted however that the 12 week trial had a high drop out rate of 30% which could have skewed the results.

The authors say that no clear statement can be made on side-effects of amitriptyline treatment due to inconsistencies in the data from the studies currently available. Side-effects typically associated with the drug include daytime drowsiness/sleepiness and dry mouth.

They do conclude that: "A definitive clinical recommendation regarding the efficacy of amitriptyline for FM symptoms cannot be made. There is some evidence to support the short-term efficacy of amitriptyline 25 mg/day in FM. There is no evidence to support the efficacy of amitriptyline at higher doses or for periods >8 weeks. More stringent RCTs with longer follow-up periods are required to determine the long-term efficacy and safety of amitriptyline and define its role in the multidisciplinary management of FM."

This review of the research is enlightening as many authorities advise prolonged trials of amitriptyline for fibromyalgia with periodic increases in dose. It seems from this review that this approach may be a waste of time for both patient and doctor as optimum benefits are seen at the low dose of 25 mg/day. The researchers concluded that there was no evidence that amitriptyline helps for periods longer than 12 weeks but this may purely be due to a lack of evidence. As they say, further study over longer time periods is required to determine just how helpful amitriptyline is in fibromyalgia.

Rodger Murphree, M.D. who specializes in fibromyalgia believes that effective alternatives to amitriptyline include 5-HTP, a precursor to the neurotransmitter serotonin, and melatonin, which is derived from serotonin and produced at night to promote sound sleep. Both are available as nutritional supplements or by prescription depending on country.

Jacob Teitelbaum, M.D., Medical Director of Fibromyalgia & Fatigue Centers, Inc., also recommends 5-HTP and melatonin as well as other natural remedies including the herbs valerian and passion flower, as well as good sleep hygience practices such as having a regular bed time and reducing activity and exposure to bright light in the evenings.



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