Is SNRI Treatment of Fibromyalgia Working? Look at Sleep Patterns

Not a morning person? For patients with fibromyalgia, the answer to that question could be a clue about their treatment response with a serotonin and norepinephrine reuptake inhibitor (SNRI), suggested a new cross-sectional study published in Rheumatology International.

Compared with patients who had 30% or more pain relief after 8 or more weeks on an SNRI (duloxetine, venlafaxine, or milnacipran), those with less pain relief reported rougher mornings and worse sleep overall. Morningness, morning affect, diurnal dysrhythmia, anytime wakeability, overall sleep quality, subjective sleep quality and disturbances, sleep medication use, and daytime dysfunction were all predictors of nonresponse to SNRI treatment.

“The observed chronobiological characteristics of patients resistant to SNRI treatment are important because they can be targeted with adjunctive circadian interventions, ie, morning light therapy, in order to normalize circadian rhythms and improve sleep, and in effect, overcome the resistance to treatment and alleviate [the] patient’s pain,” said study author Anna Julia Krupa, MD, a psychiatrist and research assistant in the Department of Affective Disorders at Jagiellonian University Medical College, Kraków, Poland.

Fibromyalgia symptoms like sleep disturbance, low mood, fatigue, stiffness, cognitive impairment, and anxiety are often interlinked in positive feedback loops, meaning that the presence of one symptom (ie, sleep problems or depression) exacerbates the other (ie, pain or anxiety), Dr. Krupa said. While SNRIs can reduce pain, anxiety, and depression, they don’t directly improve sleep. Sometimes, pain relief smooths out minor sleep problems, but not always.

“Therefore, if circadian rhythm disruptions and sleep problems are significant, they may constitute a factor which limits SNRI effects on pain in people with fibromyalgia,” Dr. Krupa said.

With 60 patients with fibromyalgia (30 responsive to treatment and 30 nonresponsive to treatment) and 30 healthy controls, this was a small study, noted Daniel G. Arkfeld, MD, DDS, a rheumatologist and associate professor of clinical medicine at Keck School of Medicine, University of Southern California, Los Angeles. However, “sleep is probably one of the most difficult things in fibromyalgia, and it definitely needs to be targeted.”

Decades of research suggest that important neurochemicals, like growth hormone, are released in deep sleep. “We know that sleep disturbances and time frame and release of neurochemicals [are] all super important in fibromyalgia,” he said.

Side effects of medication could be another factor at play here. As with any drug, the side effects of SNRIs vary widely from person to person, but palpitations, tremulousness, and insomnia are common, said Daniel J. Clauw, MD, professor of anesthesiology, internal medicine/rheumatology, and psychiatry and director of the Chronic Pain & Fatigue Research Center at the University of Michigan, Ann Arbor.

“SNRIs are often ‘activating’ because of the increase in norepinephrine,” Dr. Clauw said. “This is often helpful for symptoms such as fatigue and memory problems — but could worsen sleep.”

That’s why he always recommends that patients take an SNRI in the morning, not at night. Try that and the following tips to help patients with fibromyalgia sleep better and feel better, too.

Start with the basics. It’s worth reminding patients about the tried-and-true tips like going to bed and waking up at the same time every day and keeping your bedroom quiet and dark. “Patients should first try ‘sleep hygiene’ strategies,” said Dr. Clauw. “If that doesn’t help then cognitive-behavioral therapy (CBT) for insomnia can be very helpful.”

A systematic review and meta-analysis showed that CBT for insomnia helped patients with fibromyalgia improve sleep quality, pain, anxiety, and depression compared with nonpharmacologic treatments. And if that doesn’t help? “If need be, they can try nonbenzodiazepine hypnotic drugs, eg, tricyclics or gabapentinoids taken at bedtime,” said Dr. Clauw.

Help them fall in love with exercise. A personalized approach to exercise can help patients with fibromyalgia feel better, suggested a study review in Clinical and Experimental Rheumatology. Exercise can also help reset the circadian clock. Morning activity helps night owls get on an earlier schedule, suggested a study review published in Physical Activity and Nutrition. 

Consider yoga, tai chi, or qigong. A study review published in Seminars in Arthritis and Rheumatism suggested mind-body and combined exercises help improve sleep for people with fibromyalgia, while aerobic or strength training alone does not. One explanation is that mind-body exercises might do more than other types to tamp down sympathetic-excitatory overactivation in fibromyalgia, the researchers said. Use this handy guide from the European Pain Federation to help you start the exercise conversation.

Talk about sleep alongside other aspects of fibromyalgia. Psychoeducation for fibromyalgia often includes information about the distinction between acute and chronic pain, the nature of fibromyalgia syndrome, disease-contributing factors, safe and effective treatments, symptoms and characteristics, and coping strategies, according to a study review in the journal Behavioral Sciences. “As a psychiatrist and someone who often consults patients with fibromyalgia, I would also add the information about links between pain and mood, anxiety as well as sleep,” said Dr. Krupa.

Try morning light. Use light to shift circadian rhythms, suggested Dr. Krupa. People who struggle in the morning might benefit from 30-60 minutes of morning light therapy immediately after waking using a 10,000-lux light box or light glasses, as suggested by a study review from the University of Michigan.

Help them get off the night shift. “Fibromyalgia patients probably shouldn’t work the night shift and throw their circadian rhythm off,” said Dr. Arkfeld. Depending on a patient’s work and financial circumstances, a job change might not be possible, but consider writing a note to the patient’s employer asking them to switch the patient to the day shift. Dr. Arkfeld said this approach has worked for some of his patients.

Refer them for a sleep study. Many patients with fibromyalgia have obstructive sleep apnea or other sleep disorders that require additional intervention. “Sleep studies are important to kind of define the actual sleep problem that’s occurring as well, whether it’s the stage for interruption of sleep or sleep apnea or wakefulness,” said Dr. Arkfeld.

The study was funded by Jagiellonian University Medical College. The authors had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Not a morning person? For patients with fibromyalgia, the answer to that question could be a clue about their treatment response with a serotonin and norepinephrine reuptake inhibitor (SNRI), suggested a new cross-sectional study published in Rheumatology International.

Compared with patients who had 30% or more pain relief after 8 or more weeks on an SNRI (duloxetine, venlafaxine, or milnacipran), those with less pain relief reported rougher mornings and worse sleep overall. Morningness, morning affect, diurnal dysrhythmia, anytime wakeability, overall sleep quality, subjective sleep quality and disturbances, sleep medication use, and daytime dysfunction were all predictors of nonresponse to SNRI treatment.

“The observed chronobiological characteristics of patients resistant to SNRI treatment are important because they can be targeted with adjunctive circadian interventions, ie, morning light therapy, in order to normalize circadian rhythms and improve sleep, and in effect, overcome the resistance to treatment and alleviate [the] patient’s pain,” said study author Anna Julia Krupa, MD, a psychiatrist and research assistant in the Department of Affective Disorders at Jagiellonian University Medical College, Kraków, Poland.

Fibromyalgia symptoms like sleep disturbance, low mood, fatigue, stiffness, cognitive impairment, and anxiety are often interlinked in positive feedback loops, meaning that the presence of one symptom (ie, sleep problems or depression) exacerbates the other (ie, pain or anxiety), Dr. Krupa said. While SNRIs can reduce pain, anxiety, and depression, they don’t directly improve sleep. Sometimes, pain relief smooths out minor sleep problems, but not always.

“Therefore, if circadian rhythm disruptions and sleep problems are significant, they may constitute a factor which limits SNRI effects on pain in people with fibromyalgia,” Dr. Krupa said.

With 60 patients with fibromyalgia (30 responsive to treatment and 30 nonresponsive to treatment) and 30 healthy controls, this was a small study, noted Daniel G. Arkfeld, MD, DDS, a rheumatologist and associate professor of clinical medicine at Keck School of Medicine, University of Southern California, Los Angeles. However, “sleep is probably one of the most difficult things in fibromyalgia, and it definitely needs to be targeted.”

Decades of research suggest that important neurochemicals, like growth hormone, are released in deep sleep. “We know that sleep disturbances and time frame and release of neurochemicals [are] all super important in fibromyalgia,” he said.

Side effects of medication could be another factor at play here. As with any drug, the side effects of SNRIs vary widely from person to person, but palpitations, tremulousness, and insomnia are common, said Daniel J. Clauw, MD, professor of anesthesiology, internal medicine/rheumatology, and psychiatry and director of the Chronic Pain & Fatigue Research Center at the University of Michigan, Ann Arbor.

“SNRIs are often ‘activating’ because of the increase in norepinephrine,” Dr. Clauw said. “This is often helpful for symptoms such as fatigue and memory problems — but could worsen sleep.”

That’s why he always recommends that patients take an SNRI in the morning, not at night. Try that and the following tips to help patients with fibromyalgia sleep better and feel better, too.

Start with the basics. It’s worth reminding patients about the tried-and-true tips like going to bed and waking up at the same time every day and keeping your bedroom quiet and dark. “Patients should first try ‘sleep hygiene’ strategies,” said Dr. Clauw. “If that doesn’t help then cognitive-behavioral therapy (CBT) for insomnia can be very helpful.”

A systematic review and meta-analysis showed that CBT for insomnia helped patients with fibromyalgia improve sleep quality, pain, anxiety, and depression compared with nonpharmacologic treatments. And if that doesn’t help? “If need be, they can try nonbenzodiazepine hypnotic drugs, eg, tricyclics or gabapentinoids taken at bedtime,” said Dr. Clauw.

Help them fall in love with exercise. A personalized approach to exercise can help patients with fibromyalgia feel better, suggested a study review in Clinical and Experimental Rheumatology. Exercise can also help reset the circadian clock. Morning activity helps night owls get on an earlier schedule, suggested a study review published in Physical Activity and Nutrition. 

Consider yoga, tai chi, or qigong. A study review published in Seminars in Arthritis and Rheumatism suggested mind-body and combined exercises help improve sleep for people with fibromyalgia, while aerobic or strength training alone does not. One explanation is that mind-body exercises might do more than other types to tamp down sympathetic-excitatory overactivation in fibromyalgia, the researchers said. Use this handy guide from the European Pain Federation to help you start the exercise conversation.

Talk about sleep alongside other aspects of fibromyalgia. Psychoeducation for fibromyalgia often includes information about the distinction between acute and chronic pain, the nature of fibromyalgia syndrome, disease-contributing factors, safe and effective treatments, symptoms and characteristics, and coping strategies, according to a study review in the journal Behavioral Sciences. “As a psychiatrist and someone who often consults patients with fibromyalgia, I would also add the information about links between pain and mood, anxiety as well as sleep,” said Dr. Krupa.

Try morning light. Use light to shift circadian rhythms, suggested Dr. Krupa. People who struggle in the morning might benefit from 30-60 minutes of morning light therapy immediately after waking using a 10,000-lux light box or light glasses, as suggested by a study review from the University of Michigan.

Help them get off the night shift. “Fibromyalgia patients probably shouldn’t work the night shift and throw their circadian rhythm off,” said Dr. Arkfeld. Depending on a patient’s work and financial circumstances, a job change might not be possible, but consider writing a note to the patient’s employer asking them to switch the patient to the day shift. Dr. Arkfeld said this approach has worked for some of his patients.

Refer them for a sleep study. Many patients with fibromyalgia have obstructive sleep apnea or other sleep disorders that require additional intervention. “Sleep studies are important to kind of define the actual sleep problem that’s occurring as well, whether it’s the stage for interruption of sleep or sleep apnea or wakefulness,” said Dr. Arkfeld.

The study was funded by Jagiellonian University Medical College. The authors had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.

Not a morning person? For patients with fibromyalgia, the answer to that question could be a clue about their treatment response with a serotonin and norepinephrine reuptake inhibitor (SNRI), suggested a new cross-sectional study published in Rheumatology International.

Compared with patients who had 30% or more pain relief after 8 or more weeks on an SNRI (duloxetine, venlafaxine, or milnacipran), those with less pain relief reported rougher mornings and worse sleep overall. Morningness, morning affect, diurnal dysrhythmia, anytime wakeability, overall sleep quality, subjective sleep quality and disturbances, sleep medication use, and daytime dysfunction were all predictors of nonresponse to SNRI treatment.

“The observed chronobiological characteristics of patients resistant to SNRI treatment are important because they can be targeted with adjunctive circadian interventions, ie, morning light therapy, in order to normalize circadian rhythms and improve sleep, and in effect, overcome the resistance to treatment and alleviate [the] patient’s pain,” said study author Anna Julia Krupa, MD, a psychiatrist and research assistant in the Department of Affective Disorders at Jagiellonian University Medical College, Kraków, Poland.

Fibromyalgia symptoms like sleep disturbance, low mood, fatigue, stiffness, cognitive impairment, and anxiety are often interlinked in positive feedback loops, meaning that the presence of one symptom (ie, sleep problems or depression) exacerbates the other (ie, pain or anxiety), Dr. Krupa said. While SNRIs can reduce pain, anxiety, and depression, they don’t directly improve sleep. Sometimes, pain relief smooths out minor sleep problems, but not always.

“Therefore, if circadian rhythm disruptions and sleep problems are significant, they may constitute a factor which limits SNRI effects on pain in people with fibromyalgia,” Dr. Krupa said.

With 60 patients with fibromyalgia (30 responsive to treatment and 30 nonresponsive to treatment) and 30 healthy controls, this was a small study, noted Daniel G. Arkfeld, MD, DDS, a rheumatologist and associate professor of clinical medicine at Keck School of Medicine, University of Southern California, Los Angeles. However, “sleep is probably one of the most difficult things in fibromyalgia, and it definitely needs to be targeted.”

Decades of research suggest that important neurochemicals, like growth hormone, are released in deep sleep. “We know that sleep disturbances and time frame and release of neurochemicals [are] all super important in fibromyalgia,” he said.

Side effects of medication could be another factor at play here. As with any drug, the side effects of SNRIs vary widely from person to person, but palpitations, tremulousness, and insomnia are common, said Daniel J. Clauw, MD, professor of anesthesiology, internal medicine/rheumatology, and psychiatry and director of the Chronic Pain & Fatigue Research Center at the University of Michigan, Ann Arbor.

“SNRIs are often ‘activating’ because of the increase in norepinephrine,” Dr. Clauw said. “This is often helpful for symptoms such as fatigue and memory problems — but could worsen sleep.”

That’s why he always recommends that patients take an SNRI in the morning, not at night. Try that and the following tips to help patients with fibromyalgia sleep better and feel better, too.

Start with the basics. It’s worth reminding patients about the tried-and-true tips like going to bed and waking up at the same time every day and keeping your bedroom quiet and dark. “Patients should first try ‘sleep hygiene’ strategies,” said Dr. Clauw. “If that doesn’t help then cognitive-behavioral therapy (CBT) for insomnia can be very helpful.”

A systematic review and meta-analysis showed that CBT for insomnia helped patients with fibromyalgia improve sleep quality, pain, anxiety, and depression compared with nonpharmacologic treatments. And if that doesn’t help? “If need be, they can try nonbenzodiazepine hypnotic drugs, eg, tricyclics or gabapentinoids taken at bedtime,” said Dr. Clauw.

Help them fall in love with exercise. A personalized approach to exercise can help patients with fibromyalgia feel better, suggested a study review in Clinical and Experimental Rheumatology. Exercise can also help reset the circadian clock. Morning activity helps night owls get on an earlier schedule, suggested a study review published in Physical Activity and Nutrition. 

Consider yoga, tai chi, or qigong. A study review published in Seminars in Arthritis and Rheumatism suggested mind-body and combined exercises help improve sleep for people with fibromyalgia, while aerobic or strength training alone does not. One explanation is that mind-body exercises might do more than other types to tamp down sympathetic-excitatory overactivation in fibromyalgia, the researchers said. Use this handy guide from the European Pain Federation to help you start the exercise conversation.

Talk about sleep alongside other aspects of fibromyalgia. Psychoeducation for fibromyalgia often includes information about the distinction between acute and chronic pain, the nature of fibromyalgia syndrome, disease-contributing factors, safe and effective treatments, symptoms and characteristics, and coping strategies, according to a study review in the journal Behavioral Sciences. “As a psychiatrist and someone who often consults patients with fibromyalgia, I would also add the information about links between pain and mood, anxiety as well as sleep,” said Dr. Krupa.

Try morning light. Use light to shift circadian rhythms, suggested Dr. Krupa. People who struggle in the morning might benefit from 30-60 minutes of morning light therapy immediately after waking using a 10,000-lux light box or light glasses, as suggested by a study review from the University of Michigan.

Help them get off the night shift. “Fibromyalgia patients probably shouldn’t work the night shift and throw their circadian rhythm off,” said Dr. Arkfeld. Depending on a patient’s work and financial circumstances, a job change might not be possible, but consider writing a note to the patient’s employer asking them to switch the patient to the day shift. Dr. Arkfeld said this approach has worked for some of his patients.

Refer them for a sleep study. Many patients with fibromyalgia have obstructive sleep apnea or other sleep disorders that require additional intervention. “Sleep studies are important to kind of define the actual sleep problem that’s occurring as well, whether it’s the stage for interruption of sleep or sleep apnea or wakefulness,” said Dr. Arkfeld.

The study was funded by Jagiellonian University Medical College. The authors had no relevant conflicts of interest.

A version of this article appeared on Medscape.com.