Pharmacological Therapy

Pregabalin (Lyrica®)

Duloxetine (Cymbalta®)

Milnacipran (Savella®)

Pregabalin

Lyrica®

Class: GABA analog

MOA: Binds to alpha-2 subunit of voltage gated Ca channel and decreases Ca influx at nerve terminals which reduce the release of excitatory NT (Glutamate and Substance P)

Dose: 300-450 mg/d; start 75 mg BID and ↑ to 150 mg BID in 1 wk

Notes: Renally adjusted; C-V

Duloxetine

Cymbalta®

Class: SNRI

MOA: Potent inhibitor of neuronal serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake

Dose: 60 mg/d; start 30 mg/d for 1 wk, then increase to 60 mg daily as tolerated

Notes: Not recommended if CrCl <30 mL/min; BBW for suicidal ideation

Milnacipran

Savella®

Class: SNRI

MOA: Potent inhibitor of norepinephrine and serotonin reuptake (3:1) and possesses some inhibitory action at NMDA receptors

Dose: 50 mg BID; start 12.5 mg once on day 1, 12.5 mg BID on days 2-3, 25 mg BID on days 4-7, then 50 mg BID thereafter. Dose may be ↑ to 100 mg BID

Notes: Must be titrated due to severe nausea; If DC, must be titrated down; Renally dosed: CrCl 5-29, ↓ dose 50%

Alternative Pharmacotherapy

Amitriptyline (Elavil®)

Cyclobenzaprine (Flexeril®)

Trazodone (Desyrel®)

Tramadol (Ultram®)

Lubiprostone (Amitiza®)

Dicyclomine (Bentyl®)

Amitriptyline

Elavil®

Class: TCA

MOA: Increased synaptic concentration of serotonin and norepinephrine in CNS by inhibiting their reuptake

Dose: 10-50 mg HS

Cyclobenzaprine

Flexeril®

Class: Centrally Acting Skeletal Muscle Relaxant

MOA: Centrally acting skeletal muscle relaxant

Dose: 10-40 mg/d

Trazodone

Desyrel®, Oleptro®

Class: Miscellaneous antidepressant

MOA: Inhibits reuptake of serotonin, blocks histamine, and alpha-1 adrenergic receptors

Dose: 25-100 mg HS

Tramadol

Ultram®

Class: Opioid analgesic

MOA: Agonist of mu-opiate receptors in CNS inhibiting ascending pain pathways, altering perception and response to pain while also inhibiting the reuptake of norepinephrine and serotonin

Dose: 50-100 mg q4-6 hrs

Lubiprostone

Amitiza®

Class: Chloride Channel Activator

MOA: Activates intestinal chloride channels which increases intestinal fluid secretion and motility

Dose: 8 mcg BID

Dicyclomine

Bentyl®

Class: Antispasmodics

MOA: Antispasmodic and anticholinergic activity which alleviate smooth muscles spasms of GI tract

Dose: 20 mg QID