Milnacipran for Treatment of Fibromyalgia

• Published in: The Annals of pharmacotherapy Vol. 44; no. 9; pp. 1422 - 1429
• Main Authors: KYLE, Jeffrey A, DUGAN, B. Deeann, TESTERMAN, Kristian K, LUGO, Sonia I, PAQUETTE-LAMONTAGNE, Nicolas
• Format: Journal Article
• Language: English
• Published: Cincinnati, OH Whitney 01-09-2010
• Subjects: Animals; Biological and medical sciences; Cyclopropanes - pharmacokinetics; Cyclopropanes - pharmacology; Cyclopropanes - therapeutic use; Diseases of the osteoarticular system; Dose-Response Relationship, Drug; Fibromyalgia - drug therapy; Humans; Medical sciences; Miscellaneous. Osteoarticular involvement in other diseases; Pharmacology. Drug treatments; Serotonin Uptake Inhibitors - pharmacokinetics; Serotonin Uptake Inhibitors - pharmacology; Serotonin Uptake Inhibitors - therapeutic use; Human; serotonin-norepinephrine reuptake inhibitor; Serotonin; Psychotropic; Diseases of the osteoarticular system; Fibromyalgia; Milnacipran; Catecholamine; Reuptake inhibitor; Striated muscle disease; Chronic; Pain; Treatment; Neurotransmitter; Antidepressant agent; Norepinephrine
• ISSN: 1060-0280; 1542-6270
• DOI: 10.1345/aph.1P218

To review the pharmacology, pharmacokinetics, efficacy, and safety of milnacipran and evaluate relevant clinical trial data.
MEDLINE, International Pharmaceutical Abstracts, and Google Scholar searches (1966-June 2010) were conducted using the key words fibromyalgia, milnacipran, and serotonin-norepinephrine reuptake inhibitor. Searches were limited to articles published in English.
All available English-language articles of human studies were evaluated. One pharmacokinetic study reviewed included animal data. References cited in identified articles were used for additional evaluation.
Milnacipran is a serotonin-norepinephrine reuptake inhibitor with a 3-fold increased selectivity for norepinephrine compared to serotonin. It is well absorbed with 85-90% bioavailability. Maximum concentrations are achieved 2-4 hours after administration. Milnacipran does not undergo cytochrome P450 metabolism and has a half-life of 6-8 hours. Fifty-five percent of each dose is excreted unchanged in the urine. Dose adjustment is needed in patients with an estimated creatinine clearance of <30 mL/min. Clinical trials indicated that twice-daily dosing at 100 mg/day or 200 mg/day was superior to single-daily dosing. Studies further established the effectiveness of both doses in the treatment of fibromyalgia pain utilizing patient self-reported pain scores, as well as on a visual analog scale, Patient Global Impression of Change scale, and the Short-Form 36 Physical Component Summary. A 6-month extension trial, which evaluated patients continued on milnacipran for up to 1 year, demonstrated continued pain relief. The most common adverse drug reaction associated with milnacipran was nausea, which was reduced with slow-dose titration and administration with food.
Milnacipran is an effective treatment option for patients with fibromyalgia. More head-to-head clinical trials are necessary to assess its ultimate place in therapy.