Milnacipran has been used for several years in Europe and Asia for treating patients with depression. It was approved in 2009 as Savella in the U.S. for patients with FM. As with older drugs used for FM, milnacipran utilizes both norepinephrine and serotonin reuptake as its primary mechanisms for treating symptoms. Pregabalin and duloxetine are also used for FM. Besides FDA-approved agents, several medications have off-label usage in therapy for FM, such as gaba-pentin (Neurontin, Pfizer), tramadol (Ultram Mexico, PriCara), and amitriptyline.
In January 2010, the efficacy and safety of milnacipran were called into question. Public Citizen, a non-profit consumer advocacy group, petitioned the FDA to remove the drug from the market because of its hypertensive effects and lack of long-term evidence.20 The average increase in systolic and diastolic BP was 3.1 mm Hg with milnacipran; almost 20% of non-hypertensive patients receiving milnacipran 100 mg/day became hypertensive at the end of the study. The average increase in BP seen with milnacipran is comparable to that of other SNRIs on the market. Compared with venlafaxine and duloxetine, milnacipran has the highest selectivity for norepinephrine reuptake.
Although scrutiny should be used in prescribing milna cipran, it is still a valid option for FM based on the clinical evidence. Additional long-term studies of milnacipran are still needed because it is being used to treat a chronic disease state. One must consider the patient’s current medication profile, financial means, and coexisting disease states in order to select the most appropriate treatment.