Fibromyalgia, a chronic pain condition, is complicated both in its initial diagnosis and ongoing treatment because of a wide range of pain and nonpain symptoms including fatigue, sleep problems, depression and anxiety. Since the approval of Lilly’s Cymbalta for the treatment of fibromyalgia in June 2008, an analysis of trends in usage and perceptions for Cymbalta and its chief rival, Pfizer’s Lyrica, shows few significant changes, according to new research by GfK Healthcare.

While many different types of physicians treat fibromyalgia, rheumatologists are generally considered to be the specialists in the treatment of this disorder. However, pain specialists (anesthesiologists with pain management specialty), and physiatrists – who each often see the most difficult-to-treat pain patients – also treat fibromyalgia patients in relatively large numbers.

Importantly, as compared to other physicians, rheumatologists are more likely to consider the broader range of symptoms as important in the treatment of fibromyalgia. For example, rheumatologists tend to place a higher importance on the attributes “relieves fatigue” and “low incidence of side effects” in the decision to select a medication to treat fibromyalgia. More specifically, rheumatologists give the attribute “relieves fatigue” an average rating of 5.84 on a 7-point scale compared with an average score of 5.42 among other physicians. In terms of drug preferences, GfK’s research reveals that rheumatologists prescribe Lyrica as often as TCAs and COX-2s/Rx NSAIDs.

Among anesthesiologists and pain specialists, Lyrica continues to be the preferred first-line fibromyalgia treatment. These specialists – who tend to treat more severe pain – also rely a great deal more on opioid analgesics (21 and 11 percent respectively), while rheumatologists use few if any of these medications (5 percent). Psychiatrists, on the other hand, are the only specialists treating fibromyalgia who are most apt to prescribe Cymbalta, likely given the brand’s indication for major depressive disorder.

Lyrica appears to have a slight edge over Cymbalta for the attribute “effective for fibromyalgia pain” among anesthesiologists, physiatrists and neurologists. Among psychiatrists, primary care physicians and, importantly, rheumatologists, there are little to no differences in rating scores. In fact, rheumatologists had rated Lyrica higher in GfK’s research conducted June 2008, but that gap has closed as of GfK’s most recent measure in February.

While much has been made of the Lyrica and Cymbalta rivalry, each brand’s success is less about a head-to-head competition. Rather, patients currently on Lyrica were most likely using generic gabapentin (Neurontin). For example, 59 percent of physicians report Neurontin as the drug most often displaced by Lyrica use. For current Cymbalta users, prior drugs were more often older antidepressants like TCAs or SSRIs (with no current indications for fibromyalgia). As well, in some instances both brands are being prescribed in combination.

On the key secondary symptoms, such as sleep and depression, each brand seems to own one of these symptoms. As an antidepressant, across all specialties, Cymbalta wins on reducing depression. Similarly, among all specialties, except anesthesiologists, Cymbalta tends to be favored for the relief of fatigue. Lyrica appears to be better perceived in helping to improve sleep, especially among anesthesiologists, neurologists and psychiatrists.

“The challenge for marketers is that the range of fibromyalgia symptoms cross two very different specialty areas in pain management and psychiatry – pain specialists, who are unfamiliar with psychotropic medications, and psychiatrists, who are not accustomed to prescribing opioids or combination pain therapies,” said Geoff Penney, Vice President and Category Business Leader, Neurology, GfK Healthcare. “Rheumatologists appear willing to at least acknowledge the importance of treating all symptoms.”

Contact: Geoff Penney, VP, Category Business Leader, Neurology
geoff.penney@gfk.com