Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia

Patrick Welsch, Nurcan Üçeyler, Petra Klose, Brian Walitt, Winfried Häuser, Patrick Welsch, Nurcan Üçeyler, Petra Klose, Brian Walitt, Winfried Häuser

Abstract

Background: Fibromyalgia is a clinically defined chronic condition of unknown etiology characterized by chronic widespread pain that often co-exists with sleep disturbances, cognitive dysfunction and fatigue. People with fibromyalgia often report high disability levels and poor quality of life. Drug therapy, for example, with serotonin and noradrenaline reuptake inhibitors (SNRIs), focuses on reducing key symptoms and improving quality of life. This review updates and extends the 2013 version of this systematic review.

Objectives: To assess the efficacy, tolerability and safety of serotonin and noradrenaline reuptake inhibitors (SNRIs) compared with placebo or other active drug(s) in the treatment of fibromyalgia in adults.

Search methods: For this update we searched CENTRAL, MEDLINE, Embase, the US National Institutes of Health and the World Health Organization (WHO) International Clinical Trials Registry Platform for published and ongoing trials and examined the reference lists of reviewed articles, to 8 August 2017.

Selection criteria: We selected randomized, controlled trials of any formulation of SNRIs against placebo or any other active treatment of fibromyalgia in adults.

Data collection and analysis: Three review authors independently extracted data, examined study quality, and assessed risk of bias. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 50% or greater and of 30% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardized mean differences (SMD) for fatigue, sleep problems, health-related quality of life, mean pain intensity, depression, anxiety, disability, sexual function, cognitive disturbances and tenderness. For tolerability we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawals due to adverse events and for nausea, insomnia and somnolence as specific adverse events. For safety we calculated NNTH for serious adverse events. We undertook meta-analysis using a random-effects model. We assessed the evidence using GRADE and created a 'Summary of findings' table.

Main results: We added eight new studies with 1979 participants for a total of 18 included studies with 7903 participants. Seven studies investigated duloxetine and nine studies investigated milnacipran against placebo. One study compared desvenlafaxine with placebo and pregabalin. One study compared duloxetine with L-carnitine. The majority of studies were at unclear or high risk of bias in three to five domains.The quality of evidence of all comparisons of desvenlafaxine, duloxetine and milnacipran versus placebo in studies with a parallel design was low due to concerns about publication bias and indirectness, and very low for serious adverse events due to concerns about publication bias, imprecision and indirectness. The quality of evidence of all comparisons of duloxetine and desvenlafaxine with other active drugs was very low due to concerns about publication bias, imprecision and indirectness.Duloxetine and milnacipran had no clinically relevant benefit over placebo for pain relief of 50% or greater: 1274 of 4104 (31%) on duloxetine and milnacipran reported pain relief of 50% or greater compared to 591 of 2814 (21%) participants on placebo (risk difference (RD) 0.09, 95% confidence interval (CI) 0.07 to 0.11; NNTB 11, 95% CI 9 to 14). Duloxetine and milnacipran had a clinically relevant benefit over placebo in patient's global impression to be much or very much improved: 888 of 1710 (52%) on duloxetine and milnacipran (RD 0.19, 95% CI 0.12 to 0.26; NNTB 5, 95% CI 4 to 8) reported to be much or very much improved compared to 354 of 1208 (29%) of participants on placebo. Duloxetine and milnacipran had a clinically relevant benefit compared to placebo for pain relief of 30% or greater. RD was 0.10; 95% CI 0.08 to 0.12; NNTB 10, 95% CI 8 to 12. Duloxetine and milnacipran had no clinically relevant benefit for fatigue (SMD -0.13, 95% CI -0.18 to -0.08; NNTB 18, 95% CI 12 to 29), compared to placebo. There were no differences between either duloxetine or milnacipran and placebo in reducing sleep problems (SMD -0.07; 95 % CI -0.15 to 0.01). Duloxetine and milnacipran had no clinically relevant benefit compared to placebo in improving health-related quality of life (SMD -0.20, 95% CI -0.25 to -0.15; NNTB 11, 95% CI 8 to 14).There were 794 of 4166 (19%) participants on SNRIs who dropped out due to adverse events compared to 292 of 2863 (10%) of participants on placebo (RD 0.07, 95% CI 0.04 to 0.10; NNTH 14, 95% CI 10 to 25). There was no difference in serious adverse events between either duloxetine, milnacipran or desvenlafaxine and placebo (RD -0.00, 95% CI -0.01 to 0.00).There was no difference between desvenlafaxine and placebo in efficacy, tolerability and safety in one small trial.There was no difference between duloxetine and desvenlafaxine in efficacy, tolerability and safety in two trials with active comparators (L-carnitine, pregabalin).

Authors' conclusions: The update did not change the major findings of the previous review. Based on low- to very low-quality evidence, the SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in the frequency of pain relief of 50% or greater, but for patient's global impression to be much or very much improved and in the frequency of pain relief of 30% or greater there was a clinically relevant benefit. The SNRIs duloxetine and milnacipran provided no clinically relevant benefit over placebo in improving health-related quality of life and in reducing fatigue. Duloxetine and milnacipran did not significantly differ from placebo in reducing sleep problems. The dropout rates due to adverse events were higher for duloxetine and milnacipran than for placebo. On average, the potential benefits of duloxetine and milnacipran in fibromyalgia were outweighed by their potential harms. However, a minority of people with fibromyalgia might experience substantial symptom relief without clinically relevant adverse events with duloxetine or milnacipran.We did not find placebo-controlled studies with other SNRIs than desvenlafaxine, duloxetine and milnacipran.

Conflict of interest statement

PW: none known. PW is a specialist pain physician and manages patients with fibromyalgia.

NÜ is a neurologist and pain physician who treats patients with fibromyalgia. She is member of the German guideline group on fibromyalgia. She received travel grants, research support and speaker honoraria from Genzyme (2015, 2016). She received speaker honoraria from Baxalta (2016). She received research grants from Genzyme (2015) and Shire (2017). She received travel grants from Grunenthal (2017).

PK: none known

BW: none known; BW is a specialist pain physician and manages patients with fibromyalgia.

WH is a specialist in general internal medicine, psychosomatic medicine and pain medicine, who treats patients with fibromyalgia and chronic neuropathic pain. He is a member of the medical board of the German Fibromyalgia Association. He is the head of the steering committee of the German guideline on fibromyalgia and a member of the steering committee of the European League Against Rheumatism (EULAR) update recommendations on the management of fibromyalgia. He received speaking fees for one educational lecture from Grünenthal (2015) on pain management.

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1. Analysis
1.1. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 1: Self‐reported pain relief of 50% or greater
1.2. Analysis
1.2. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 2: PGIC much or very much improved
1.3. Analysis
1.3. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 3: Withdrawal due to adverse events
1.4. Analysis
1.4. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 4: Serious adverse events
1.5. Analysis
1.5. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 5: Self‐reported fatigue
1.6. Analysis
1.6. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 6: Self‐reported sleep problems
1.7. Analysis
1.7. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 7: Self‐reported health‐related quality of life
1.8. Analysis
1.8. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 8: Self‐reported pain relief of 30% or greater
1.9. Analysis
1.9. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 9: Self‐reported mean pain intensity
1.10. Analysis
1.10. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 10: Self‐reported depression
1.11. Analysis
1.11. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 11: Self‐reported anxiety
1.12. Analysis
1.12. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 12: Self‐reported disability
1.13. Analysis
1.13. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 13: Self‐reported cognitive disturbances
1.14. Analysis
1.14. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 14: Tenderness
1.15. Analysis
1.15. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 15: Withdrawal due to lack of efficacy
1.16. Analysis
1.16. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 16: Nausea
1.17. Analysis
1.17. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 17: Somnolence
1.18. Analysis
1.18. Analysis
Comparison 1: SNRIs versus placebo in parallel and cross‐over design trials, Outcome 18: Insomnia

References

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NCT00793520 {published data only}
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NCT01108731 {published data only}
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NCT01173055 {published data only}
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NCT01234675 {published data only}
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NCT01294059 {published data only}
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