Diffuse pain, overwhelming fatigue, repeated medical appointments: fibromyalgia weighs heavily on daily life, but also on the collective wallet. Between old, inexpensive antidepressants and more recent molecules, the question remains: which treatment really offers the best impact at the lowest cost?
So what is the best fibromyalgia medication when we put everything on the table?
Fibromyalgia: compare treatments
The figures from the study published in JAMA Network Open
are hitting: fibromyalgia affects approximately 2 to 6% of adults, its health costs have almost tripled, and productivity losses exceed 1% of American GDP. The search for treatments that are both effective and affordable could revolutionize symptom management for millions of people suffering from this condition.
Researchers compared four leading drugs used in adults with moderate to severe fibromyalgia: amitriptyline, pregabalin (Lyrica and generic), duloxetine (Cymbalta and generic), and milnacipran. These drugs are approved in France for this indication as well as in the United States (where amitriptyline, older, remains widely prescribed on the advice of experts such as the American College of Rheumatology).
To compare these options, the team used a probability model (Markov model) following patients to simulate disease progression over time and predict long-term costs and quality of life for each treatment over their lifetime. For each treatment, it estimated life years adjusted for quality of life (QALY) and costs, for the health system and for society, with work stoppage and informal support.
Duloxetine 120 mg, winner at the best cost
In the model, amitriptyline served as reference with 9.99 QALY. Duloxetine 120 mg rose to 10.40 QALY, for a direct cost close to around $115,000, or a little over €100,000. Pregabalin 450 mg achieved 10.23 QALYs but was more expensive, while milnacipran and lower doses were more expensive and less effective than amitriptyline.
When we add indirect costs, the hierarchy becomes clearer. From a societal perspective, the duloxetine 120 mg offered the best quality of life (10.40 QALY) for the lowest total cost, approximately $712,910 (more than €650,000). Next came:
- Pregabalin 450 mg, cheaper and more effective than amitriptyline,
- Then amitriptyline, ahead of all other dominated regimens.
A clear winner, but a personal choice
In simulations, duloxetine 120 mg has the highest probability of being the most cost-effective treatment, but no option exceeds about a 55% chance of coming out on top. The authors emphasize caution: “Clinical decisions should also take into account adverse event profiles, patient comorbidities and expected variability in treatment response.“, they wrote.
This cost-effectiveness analysis reveals that duloxetine 120 mg and pregabalin 450 mg reduce total costs while generating more quality-adjusted life years (QALYs) than amitriptyline, from the perspective of the US healthcare system. For a patient in France, these data do not dictate a prescription, they above all provide a framework for discussion. They suggest that, if duloxetine at an optimal dose is tolerated, it can limit pain, repeated consultations and work stoppages. But the European recommendations also remind us that adapted physical exercise remains the most strongly recommended intervention, to be combined with medications rather than opposed.