Fibromyalgia syndrome (FMS) is a widespread
pain condition associated with
fatigue,
cognitive dysfunction, sleep disturbance, depression, anxiety, and stiffness.
Milnacipran is one of three medications currently approved by the Food and Drug Administration in the United States for the management of adult FMS patients. This review is the second in a three-part series reviewing each of the approved FMS drugs and serves as a primer on the use of
milnacipran in FMS treatment including information on pharmacology, pharmacokinetics, safety and tolerability.
Milnacipran is a mixed
serotonin and
norepinephrine reuptake inhibitor thought to improve FMS symptoms by increasing
neurotransmitter levels in descending central nervous system inhibitory pathways.
Milnacipran has proven efficacy in managing global FMS symptoms and
pain as well as improving symptoms of
fatigue and
cognitive dysfunction without affecting sleep. Due to its
antidepressant activity,
milnacipran can also be beneficial to FMS patients with coexisting depression. However, side effects can limit
milnacipran tolerability in FMS patients due to its association with
headache,
nausea,
tachycardia, hyper- and
hypotension, and increased risk for
bleeding and suicidality in at-risk patients. Tolerability can be maximized by starting at low dose and slowly up-titrating if needed. As with all medications used in FMS management,
milnacipran works best when used as part of an individualized treatment regimen that includes resistance and aerobic exercise, patient education and behavioral
therapies.