Arthur Huppert, MD
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Huppert A. Management of Fibromyalgia. Ann Intern Med. 2000;132:1004. doi: 10.7326/0003-4819-132-12-200006200-00018
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Published: Ann Intern Med. 2000;132(12):1004.
TO THE EDITOR:
I commend Dr. Leventhal (1) for an overall superb review of fibromyalgia management and Annals for providing a prominent position for this topic.
Fibromyalgia is universally encountered in internal medicine practices and is often misunderstood and misdiagnosed. I wish to raise a few points about the prominence placed by Dr. Leventhal on tramadol as an effective agent for fibromyalgia. No mention is made of the substantial side-effect profile of this medication, whereas other therapeutic agents discussed in the paper are presented in a balanced fashion. Recently, I attended a gathering of rheumatology colleagues to discuss analgesic medicine. There was near-universal rejection of tramadol as a drug of choice in the management of fibromyalgia because of its expense and side-effect profile. Clearly, as most of my colleagues agreed, there is a limited subset of patients for whom tramadol is appropriate; Dr. Leventhal, however, presents it as the analgesic of choice for fibromyalgia. In all fairness to the author, he does note that “tramadol was found to be as effective as acetaminophen with codeine in elderly patients with various chronic painful conditions, including fibromyalgia.” Left out is the vast cost differential between tramadol and acetaminophen with codeine. Many managed care formularies have noted this and have appropriately excluded tramadol from their list of reimbursable medications. Because the paper was supported by an “unrestricted educational grant from Ortho-McNeil Pharmaceutical,” such an omission becomes understandable. Although unimpeachable in every other way, this paper must be considered an “informational” (paid advertisement presented as factual information) for tramadol. The cursory reader is lead to believe that tramadol is the proven best analgesic for fibromyalgia. This is clearly not the case.
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