1. Pharmacologic Therapy in Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFS) Daniel J. Clauw M.D.

2. Symptoms Psychological and Behavioral Consequences Decreased activity Poor sleep Increased distress Maladaptive illness behaviors Psychological and Behavioral Consequences Decreased activity Poor sleep Increased distress Maladaptive illness behaviors Dually Focused Treatment “STRESS” POOR ENVIRONMENT BAD GENES

3. Some Benefit Tricyclic compounds Amitriptyline (Elavil) and Cyclobenzaprine (Flexeril) best studied Tolerability improved by giving single dose several hours before bedtime Start low, go slow. Begin with 5 or 10 mg and increase to 30 - 40 of cyclobenzaprine or 50 – 70 mg amitriptyline Of most benefit in treating pain, insomnia; less improvement in fatigue Tricyclic compounds Amitriptyline (Elavil) and Cyclobenzaprine (Flexeril) best studied Tolerability improved by giving single dose several hours before bedtime Start low, go slow. Begin with 5 or 10 mg and increase to 30 - 40 of cyclobenzaprine or 50 – 70 mg amitriptyline Of most benefit in treating pain, insomnia; less improvement in fatigue

4. Some Benefit Other classes of neuroactive compounds – MAO inhibitors – Mixed serotinergic / noradrenergic compounds – SSRI generally ineffective – Gabapentin (Neurontin) for pain – Tramadol (Ultram) for pain Other classes of neuroactive compounds – MAO inhibitors – Mixed serotinergic / noradrenergic compounds – SSRI generally ineffective – Gabapentin (Neurontin) for pain – Tramadol (Ultram) for pain

5. No benefit / possible harm Corticosteroids Immune-based therapies Anti-infective therapies Anti-allergy therapies Fludrocortisone (Florinef) Nutritional supplements – Mg, NADH, essential fatty acids Corticosteroids Immune-based therapies Anti-infective therapies Anti-allergy therapies Fludrocortisone (Florinef) Nutritional supplements – Mg, NADH, essential fatty acids