Drug of Choice for Fibromyalgia in Heart Failure Patients

Rationale for Amitriptyline Selection

• The European League Against Rheumatism (EULAR) guidelines provide weak recommendations for amitriptyline at low doses, with Level Ia evidence, for fibromyalgia management, and amitriptyline received 100% agreement among the expert panel as a treatment option 1
• The American College of Cardiology (ACC) and American Heart Association (AHA), as well as the European Society of Cardiology (ESC), recommend avoiding medications that worsen heart failure, such as calcium channel blockers, NSAIDs, and most antiarrhythmic drugs, in heart failure patients 2, 3, 4

Safety in Heart Failure Context

• Calcium channel blockers, such as diltiazem and verapamil, are contraindicated in heart failure with reduced ejection fraction as they increase the risk of heart failure worsening and hospitalization, according to the ESC guidelines 2, 4
• NSAIDs should be avoided in heart failure patients as they cause sodium and water retention and blunt diuretic effects, as recommended by the ACC/AHA guidelines 3
• Most antiarrhythmic drugs, except amiodarone and dofetilide, increase mortality in heart failure, according to the ACC/AHA guidelines 3

Practical Implementation Algorithm

• The ACC recommends monitoring for orthostatic hypotension, anticholinergic effects, and sedation when initiating amitriptyline therapy in heart failure patients 6, 5
• The ESC guidelines recommend ensuring optimal heart failure management with ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists, as indicated, before initiating amitriptyline therapy 2, 4
• The ACC/AHA guidelines recommend monitoring for fluid retention, electrolytes, and renal function regularly in heart failure patients on amitriptyline therapy 5

Important Caveats

• The EULAR guidelines emphasize the importance of prioritizing non-pharmacological approaches, such as aerobic and strengthening exercise, and cognitive behavioral therapies, for fibromyalgia management, with strong and weak recommendations, respectively, and Level Ia evidence 1
• The EULAR guidelines also recommend setting realistic expectations about modest benefits and being cautious about drug interactions, particularly with other medications that prolong QT interval or have anticholinergic effects, in fibromyalgia patients on amitriptyline therapy 1