Pharmacological and non-hormonal treatment of hot flashes in breast cancer survivors: CEPO review and recommendations

Purpose

Breast cancer patients frequently report hot flashes. Given that conventional hormone replacement therapy is generally contraindicated for them, other therapeutic modalities must be considered. The purpose of this review was to develop evidence-based recommendations on non-hormonal pharmacological interventions, including natural health products, for managing hot flashes in women undergoing treatment for breast cancer or with a history of breast cancer.

Methods

A review of the scientific literature published between January 2000 and December 2011 was performed. A total of 26 randomized trials were identified.

Results

Studies showed that serotonin–norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, antihypertensives and anticonvulsants significantly reduced the frequency and severity of hot flashes in breast cancer patients.

Conclusions

Considering the evidence available to date, the CEPO recommends the following: (1) for breast cancer patients being treated with tamoxifen: (a) the use of venlafaxine, citalopram, clonidine, gabapentin and pregabalin be considered effective in treating hot flashes and (b) the use of paroxetine and fluoxetine be avoided, given that they may reduce the efficacy of tamoxifen; (2) for breast cancer patients not being treated with tamoxifen: (a) the use of venlafaxine, paroxetine, citalopram, clonidine, gabapentin and pregabalin be considered effective in treating hot flashes and (b) fluoxetine not be used to treat hot flashes, given that there is insufficient evidence for its therapeutic efficacy and (3) for breast cancer survivors, sertraline, phytoestrogens, black cohosh and St. John’s wort not be used to treat hot flashes.     

Behandlung der Diarrhö mit Loperamid in der Palliativmedizin

Diarrhea is a distressing symptom which limits the quality of life in patients receiving palliative care and is associated with high morbidity and mortality. In patients with AIDS, it is a more common problem than for other entities (e.g., cancer). Loperamide is considered the first choice medication for the symptomatic treatment of diarrhea. This literature review examines the efficacy of loperamide in the symptomatic treatment of diarrhea in palliative care. Two databases (Medline and Embase) were searched through June 2012. A total of 286 studies were identified, but only 7 met the inclusion criteria (1 cohort and 6 experimental studies) in which loperamide (alone or in combination) was tested. There is a lack of significant studies which investigate the efficacy of loperamide in the symptomatic treatment of diarrhea. Two trials indicated superiority of loperamide over placebo. In comparison with octreotide, the results were contradictory. The combination of acetorphan with loperamide was more effective than acetorphan alone, but the combination of loperamide with diphenoxylate was inferior to octreotide. The identified studies revealed methodical problems. A definite recommendation for administration of loperamide can, therefore, not be derived from this work. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

加巴喷丁与普瑞巴林治疗带状疱疹后神经痛的效果比较

目的观察加巴喷丁和普瑞巴林治疗带状疱疹后神经痛(post-herpetic neuralgia,PHN)的效果以及对患者睡眠的影响。方法 60例PHN患者按随机数字表法分为加巴喷丁组和普瑞巴林组各30例,分别给予加巴喷丁900 mg/d口服和普瑞巴林150 mg/d口服,疗程均为28天。观察治疗前后疼痛和睡眠的改善情况及药物不良反应。结果两组患者治疗后各时点与治疗前相比疼痛评分随时间下降,睡眠时间增加(P<0.05);普瑞巴林组治疗后各时点的疼痛视觉模拟评分(Visualanalogue scale,VAS)低于加巴喷丁组(P<0.05),24小时睡眠时间大于加巴喷丁组(P<0.05);两组未出现严重的药物不良反应,普瑞巴林组嗜睡发生率明显低于加巴喷丁组(P<0.05),其余不良反应发生率两组间比较差异均无统计学意义(P>0.05)。结论普瑞巴林治疗PHN更安全有效,优于加巴喷丁。     

Clinical Characteristics,Pharmacotherapy, and Healthcare Resource Use among Patients with Diabetic Neuropathy Newly Prescribed Pregabalin or Gabapentin

Objective: To characterize comorbidities, pain‐related pharmacotherapy, and healthcare resource use among patients with painful diabetic peripheral neuropathy (pDPN) newly prescribed pregabalin or gabapentin in clinical practice. Methods: Using the LifeLink^? Health Plan Claims Database, patients with pDPN (ICD‐9‐CM codes 357.2 or 250.6) newly prescribed (index event) gabapentin (n = 1,178; 56.9 ± 10.3 years old) were identified and propensity score‐matched with patients initiated on pregabalin (n = 1,178; 56.4 ± 9.8 years old). Comorbidities, pain‐related pharmacotherapy, and healthcare resource use/costs were examined during the 12‐month pre‐index and follow‐up periods. Results: Both cohorts were characterized by multiple comorbidities and substantial use of pain‐related and adjunctive medications. In the pregabalin cohort, the use of tricyclic antidepressants significantly decreased (16.0% vs. 13.2%) and nonsteroidal anti‐inflammatory drugs (30.8% vs. 34.8%), muscle relaxants (19.2% vs. 22.9%), anticonvulsants (14.4% vs. 18.1%), benzodiazepines (22.3% vs. 25.0%), and topical agents (7.0% vs. 9.8%) increased (P < 0.05) in the follow‐up period. In the gabapentin cohort, there were significant increases (P < 0.05) in the use of short‐acting (55.4% vs. 61.2%) and long‐acting (9.4% to 12.8%) opioids, serotonin–norepinephrine re‐uptake inhibitors (14.2% vs. 16.7%), anticonvulsants (7.1% vs. 19.2%), benzodiazepines (19.1% vs. 24.3%), sedative/hypnotics (14.9% vs. 18.0%), and tramadol (13.3% vs. 16.8%). There were significant increases (P < 0.05) in pharmacy, outpatient, and total costs in both cohorts and in costs of physician office visits in the gabapentin cohort. There was no difference in postindex median total costs between the pregabalin and gabapentin cohorts ($16,137 vs. $15,766). Conclusions: Patients with pDPN prescribed pregabalin and gabapentin had a substantial comorbidity and pain medication burden. Although healthcare costs increased in both groups, the increase in pain medication burden was higher in the gabapentin group. Direct medical costs were similar for both groups. Given the human and economic burden of pDPN, future research may benefit from a focus on efficacy parameters to further differentiate treatment options.     

Algorithm for neuropathic pain treatment: an evidence based proposal

New studies of the treatment of neuropathic pain have increased the need for an updated review of randomized, double-blind, placebo-controlled trials to support an evidence based algorithm to treat neuropathic pain conditions. Available studies were identified using a MEDLINE and EMBASE search. One hundred and five studies were included. Numbers needed to treat (NNT) and numbers needed to harm (NNH) were used to compare efficacy and safety of the treatments in different neuropathic pain syndromes. The quality of each trial was assessed. Tricyclic antidepressants and the anticonvulsants gabapentin and pregabalin were the most frequently studied drug classes. In peripheral neuropathic pain, the lowest NNT was for tricyclic antidepressants, followed by opioids and the anticonvulsants gabapentin and pregabalin. For central neuropathic pain there is limited data. NNT and NNH are currently the best way to assess relative efficacy and safety, but the need for dichotomous data, which may have to be estimated retrospectively for old trials, and the methodological complexity of pooling data from small cross-over and large parallel group trials, remain as limitations.     

Complementary and alternative medicine for treatment of irritable bowel syndrome

OBJECTIVE

To review the evidence supporting selected complementary and alternative medicine approaches used in the treatment of irritable bowel syndrome (IBS).

QUALITY OF EVIDENCE

MEDLINE (from January 1966), EMBASE (from January 1980), and the Cochrane Database of Systematic Reviews were searched until March 2008, combining the terms irritable bowel syndrome or irritable colon with complementary therapies, alternative medicine, acupuncture, fiber, peppermint oil, herbal, traditional, yoga, massage, meditation, mind, relaxation, probiotic, hypnotherapy, psychotherapy, cognitive therapy, or behavior therapy. Results were screened to include only clinical trials, systematic reviews, and meta-analyses. Level I evidence was available for most interventions.

MAIN MESSAGE

Soluble fibre improves constipation and global IBS symptoms. Peppermint oil alleviates IBS symptoms, including abdominal pain. Probiotic trials show overall benefit for IBS but there is little evidence supporting the use of any specific strain. Hypnotherapy and cognitive-behavioural therapy are also effective therapeutic options for appropriate patients. Certain herbal formulas are supported by limited evidence, but safety is a potential concern. All interventions are supported by systematic reviews or meta-analyses.

CONCLUSION

Several complementary and alternative therapies can be recommended as part of an evidence-based approach to the treatment of IBS; these might provide patients with satisfactory relief and improve the therapeutic alliance.     

抑郁情绪对腹泻型肠易激综合征患者临床症状的影响

目的：探讨抑郁情绪对腹泻型肠易激综合征患者临床症状的影响。方法对84例腹泻型肠易激综合征患者进行生活一般状况、症状程度、抑郁状况筛查,依据汉密顿抑郁量表评分结果将其分为抑郁组和非抑郁组,对两组临床典型症状特征及躯体症状发生率进行对比分析。结果抑郁组临床典型症状严重程度显著重于非抑郁组（P＜0．05）,两组发作频率及每次持续时间比较差异有显著性（ P＜0．05或0．01）。抑郁组躯体症状发生率为100％,非抑郁组为33．3％,抑郁组显著高于非抑郁组（χ2＝43．45,P＜0．01）。患者典型症状严重程度、发作频率、持续时间与汉密顿抑郁量表评分呈显著正相关（ P＜0．05或0．01）。结论抑郁情绪可加重腹泻型肠易激综合征患者的典型症状,常表现为明显的躯体症状。     

Where does hypnotherapy stand in the management of irritable bowel syndrome? A systematic review

BACKGROUND: Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. Despite its prevalence, there remains a significant lack of efficient medical treatment for IBS to date. However, according to some previous research studies, hypnosis has been shown to be effective in the treatment of IBS. AIM: To determine the definite efficacy of hypnosis in the treatment of irritable bowel syndrome. METHODS: A systematic review of the literature on hypnosis in the treatment of IBS from 1970 to 2005 was performed using MEDLINE. Full studies published in English were identified and selected for inclusion. We excluded case studies and those studies in which IBS symptoms were not in the list of outcome measures. All studies were reviewed on the basis of the Rome Working Team recommendations for design of IBS trials. RESULTS: From a total of 22 studies, seven were excluded. The results of the reviewed studies showed improved status of all major symptoms of IBS, extracolonic symptoms, quality of life, anxiety, and depression. Furthermore these improvements lasted 2-5 years. CONCLUSIONS: Although there are some methodologic inadequacies, all studies show that hypnotherapy is highly effective for patients with refractory IBS, but definite efficacy of hypnosis in the treatment of IBS remains unclear due to lack of controlled trials supporting this finding.     

Development and Validation of the GI-Cognitions Questionnaire

Patients with irritable bowel syndrome (IBS) have been shown to have catastrophic cognitions regarding the social and occupational consequences of GI symptoms. Moreover, the efficacy of cognitive–behavioral therapy for IBS may be partially mediated by reductions in such cognitions. We aimed to develop and validate a short self-report measure of GI specific catastrophic cognitions. The GI-Cognitions Questionnaire (GI-Cog) was administered to a total of 291 participants, including 65 IBS patients, 114 Crohn’s disease patients, 22 patients with co-morbid Crohn’s and IBS and 90 healthy controls. The GI-Cog showed high internal consistency (α = .92) and good test re-test reliability (r = .87) as well as good factor structure. It discriminated between IBS patients, Crohn’s disease patients and normal controls, and explained unique variance in GI symptom severity. The GI-Cog is a short, easy-to-administer self-report measure of GI specific catastrophic cognitions that appears to be both reliable and valid and can be used in future research on vulnerability, treatment outcome and mediators of treatment efficacy.     

Irritable bowel syndrome. Toward a biopsychosocial systems understanding

The symptoms of irritable bowel syndrome (IBS) are usually a subset of a broader problem that meets DSM-III criteria for depression, anxiety disorder, somatization disorder, or adjustment disorder. A biopsychosocial perspective that addresses multigenerational family patterns of anxiety, depression, and somatization of stress suggests guidelines for understanding and treating patients with IBS symptoms. Effective treatment focuses primarily on helping patients cope with emotional disorders and psychosocial stressors, and secondarily on direct symptom relief. Psychotherapy is a valuable adjunct to medical treatment. The medications most likely to yield lasting benefits are the antidepressants.     

Lubiprostone: chloride channel activator for chronic constipation

BACKGROUND: Chronic constipation is a common and costly health problem occurring in approximately 4.5 million Americans. Current management of constipation is suboptimal and requires a stepwise approach using a combination of laxatives to decrease symptoms. OBJECTIVE: The objective of this review was to describe the efficacy and safety of a new therapeutic entity, lubiprostone, recently approved by the US Food and Drug Administration for the treatment of chronic idiopathic constipation. METHODS: Computerized searches of MEDLINE and International Pharmaceutical Abstracts were conducted (1966-July 10, 2006). Search terms utilized were lubiprostone, RU-0211, and chronic constipation. References of selected articles were searched for additional articles or abstracts. All relevant published literature regarding lubiprostone was included in this review. Pertinent abstracts presented at meetings of the American College of Gastroenterology and Digestive Diseases Week were also included. RESULTS: Lubiprostone activates a chloride channel (ie, subtype 2) and increases chloride and fluid secretion into the intestines, resulting in relief of constipation. It is poorly absorbed after oral administration, and its metabolism occurs primarily in the stomach and jejunum. Lubiprostone was evaluated in 6 placebo-controlled, double-blind, randomized Phase II or III clinical trials. Overall, in clinical trials, >1400 patients were exposed to 24 mug of lubiprostone BID for up to 48 weeks. It improved the number of bowel movements, stool consistency, bloating, and global assessment of constipation compared with placebo (P < 0.05). Nausea was the most common adverse effect reported in clinical trials, occurring in 30.9% of patients. However, nausea was dose dependent and decreased when lubiprostone was given with food. CONCLUSIONS: Lubiprostone is the first in its class of chloride channel activators that results in improvement of symptoms of constipation. It has not been compared with other laxatives but, based on the available placebo-controlled studies, its efficacy is superior to placebo and its safety is acceptable. Considering the currently available laxatives, lubiprostone will become an additional option for the treatment of patients with chronic constipation.     

A double–blind crossover comparison study of the safety and efficacy of mebeverine with mebeverine sustained release in the treatment of irritable bowel syndrome

The safety and efficacy of the sustained release (SR) mebeverine capsule was compared to the standard plain mebeverine capsule in the treatment of 60 patients suffering from irritable bowel syndrome. Patients, with a score of at least 44 on the Kruis scale, were randomized into a twoperiod crossover trial. Each treatment period lasted for 6 weeks during which the patients took mebeverine plain 135 mg, two capsules t.i.d., or mebeverine sustained release 200 mg (SR), two capsules b.i.d. After 6 weeks of each treatment, both treatments were regarded ‘effective’ or ‘very effective’ by the patient as well as the investigator in more than 80% of the cases. After 3 weeks of the first treatment, the disease score was rated light in 73% of the patients with both medications. After 6 weeks, nine patients (33%) were symptom–free with mebeverine plain, and five (18%) with mebeverine SR. During the second treatment period the number of symptom–free cases reached about 40% with both formulations. Considering the clinical general improvement, more than 70% of all patients had improved after 3 weeks of the first treatment. An additional improvement was reported in 13 patients with mebeverine plain and in 10 patients with mebeverine SR after the next 3 weeks. Abdominal pain was still present in more than 50% of patients but with lower intensity compared with baseline values. Mean scores of efficacy were very similar for both treatments after 3 and 6 weeks (2 0 for mebeverine plain vs. 1 9 for mebeverine SR). The statistical comparison of all scores between the two formulations did not show a significant difference at any time. Very few adverse events were noted and a causal relationship with the study medications was judged as improbable or definitely unrelated. Compliance was close to 100% for most of the patients. The results of the present study indicate that the mebeverine SR capsule provides equivalent efficacy and tolerance to mebeverine plain in the treatment of irritable bowel syndrome (IBS), while reducing the number of daily doses from three to two.     

Fibromyalgia: The gastrointestinal link

Patients with fibromyalgia (FM) frequently have gastrointestinal symptoms and signs. This article critically reviews the available literature and concludes the following: evidence that inflammatory bowel disease is associated with FM is contradictory, but should be looked for in patients taking concomitant steroids; patients diagnosed with celiac disease often have a history of FM or irritable bowel syndrome (IBS) that may or may not be present; reflux, nonulcer dyspepsia, and noncardiac chest pain are common in FM patients; medications used to manage pain, inflammation, and gastrointestinal complaints confound the management of FM; and IBS affects smooth muscles and the parasympathetic nervous system, while FM patients have complaints of striated muscles and dysfunction of the sympathetic nervous system. Of those patients with FM, 30% to 70% have concurrent IBS. Small intestinal bacterial overgrowth is associated with hyperalgesia and IBS-like complaints, is common in FM, and responds transiently to antimicrobial therapy.     

Cost analysis of adding pregabalin or gabapentin to the management of community-treated patients with peripheral neuropathic pain

Objective To compare the cost of adding either pregabalin or gabapentin to the management of community‐treated patients with peripheral neuropathic pain (PNP). Methods A retrospective observational study was conducted using medical records from a Spanish health care provider claims database. Patients receiving health care for PNP, above 18 years and for which either pregabalin or gabapentin was initiated between 2006 and 2008 were included. Economic evaluation included health care resource utilization costs and costs due to sick leave. Results A total of 1163 patients with PNP were eligible for analysis: 764 were prescribed pregabalin and 399 gabapentin in addition to current pain therapy. Mean age was 59.2 years and 62.2% were female. Concomitant use of analgesics was higher in the gabapentin cohort (3.2 vs. 2.7; P = 0.003), mainly due to non‐steroidal anti‐inflammatory drugs (74.9% vs. 69.5%; P = 0.018) and opioids (27.7% vs. 17.9%; P = 0.031). Adjusted total costs per patient was lower in pregabalin‐treated patients (€2514 vs. €3241; P = 0.003), due to less sick leave (€1067 vs. €1633; P = 0.018) and lower health care costs (€1447 vs. €1609; P = 0.004). The higher acquisition cost of pregabalin (€351 vs. €191; P < 0.001) was largely compensated with lower costs in medical visits, physiotherapy, hospital stays and concomitant analgesics. Conclusions In community‐treated patients with PNP, total costs were considerably less for those patients initiated with pregabalin therapy than for those patients starting gabapentin add‐on therapy. The relatively higher treatment acquisition cost of pregabalin was largely compensated by the overall lower costs for the other components of health care resources and sick leave, thus reducing the economic impact on the health care provider's budget and society.     

Cost of treatment of peripheral neuropathic pain with pregabalin or gabapentin in routine clinical practice: impact of their loss of exclusivity

To analyze the effect of loss of exclusivity of data on the cost of treatment of peripheral neuropathic pain (PNP) with pregabalin or gabapentin in routine clinical practice. A retrospective observational study, with electronic medical records for patients enrolled at primary care centers managed by the health care provider Badalona Serveis Assistencials, who initiated treatment of PNP with pregabalin or gabapentin. The analysis used drugs and resources prices for year 2015. The 1163 electronic medical records (pregabalin; N = 764, gabapentin; N = 399) for patients (62.2% women) with a mean (standard deviation) age of 59.2 (14.7) years were analyzed. Treatment duration was slightly shorter with pregabalin than with gabapentin (5.2 vs 5.5 months; P = 0.124), with mean doses of 227.4 (178.6) mg and 900.0 (443.4) mg, respectively. The average study drug cost per patient was higher for pregabalin than for gabapentin; €214.6 (206.3) vs €157.4 (181.9), P < 0.001, although the cost of concomitant analgesic medication was lower; €176.5 (271.8) vs €306.7 (529.2), P < 0.001. The adjusted average total cost per patient was lower in those treated with pregabalin than in those treated with gabapentin; €2,413 (2119‐2708) vs €3201 (2806–3.597); P = 0.002, owing to significantly lower health care costs; €1307 (1247‐1367) vs €1538 (1458‐1618), P < 0.001, and also non‐health care costs; €1106 (819‐1393) vs €1663 (1279‐2048), P = 0.023, that was caused by a significantly lower use of concomitant medication, fewer medical visits to primary care, and fewer days of sick leave. After loss of exclusivity of both drugs, pregabalin continued to show lower health care and non‐health care costs than gabapentin in the treatment of PNP in routine clinical practice.     

Bipolar disorder and aggression

Aims: In clinical practice, overt aggressive behaviour is frequently observed in patients diagnosed with bipolar disorder. It can be dangerous and complicates patient care. Nevertheless, it has not been adequately studied as a phenomenon that is separate from other symptoms such as agitation. The aim of this review is to provide information on the prevalence, clinical context, and clinical management of aggression in patients with bipolar disorder. Methods: MEDLINE and PsycInfo data bases were searched for articles published between 1966 and November 2008 using the combination of key words ‘aggression’ or ‘violence’ with ‘bipolar disorder’. For the treatment searches, generic names of mood stabilisers and antipsychotics were used in combination with key words ‘bipolar disorder’ and ‘aggression’. No language constraint was applied. Articles dealing with children and adolescents were not included. Results: Acutely ill hospitalised bipolar patients have a higher risk for aggression than other inpatients. In a population survey, the prevalence of aggressive behaviour after age 15 years was 0.66% in persons without lifetime psychiatric disorder, but 25.34% in bipolar I disorder. Comorbidity with personality disorders and substance use disorders is frequent, and it elevates the risk of aggression in bipolar patients. Impulsive aggression appears to be the most frequent subtype observed in bipolar patients. Clinical management of aggression combines pharmacological and non‐pharmacological approaches. Discussion: A major problem with the evidence is that aggression is frequently reported only as one of the items contributing to the total score on a scale or a subscale. This makes it impossible to ascertain specifically aggressive behaviour. Large controlled head‐to‐head randomised controlled studies comparing treatments for aggressive behaviour in bipolar disorder are not yet available. There is some evidence favouring divalproex, but it is not particularly strong .We do not know if there are any efficacy differences among antipsychotics for this indication.     

Costs and health resources utilization following switching to pregabalin in individuals with gabapentin-refractory neuropathic pain: a post hoc analysis

Purpose: To analyze the changes in pain severity and associated costs resulting from resource utilization and reduced productivity in patients with gabapentin‐refractory peripheral neuropathic pain who switched to pregabalin therapy in primary care settings in Spain. Patients and Methods: This is a post hoc analysis of a 12‐week, multicentre, noninterventional cost‐of‐illness study. Patients were included in the study if they were over 18 years of age and had a diagnosis of chronic, treatment‐refractory peripheral neuropathic pain. The analysis included all pregabalin‐naïve patients who had previously shown an inadequate response to gabapentin and switched to pregabalin. Severity of pain before and after treatment with pregabalin, alone or as an add‐on therapy, was assessed using the Short‐Form McGill Pain Questionnaire (SF‐MPQ) and its related visual analogue scale (VA). Healthcare resource utilization, productivity (including lost‐workday equivalents [LWDE]), and related costs were assessed at baseline and after pregabalin treatment. Results: A total of 174 patients switched to pregabalin had significant and clinically relevant reductions in pain severity (mean [SD] change on SF‐MPQ VA scale, ?31.9 [22.1]; P < 0.05 vs. baseline; effect size, 1.87). Reduction in pain was similar with both pregabalin monotherapy and add‐on therapy. Significant reductions in healthcare resource utilization (concomitant drug use [in pregabalin add‐on group], ancillary tests, and unscheduled medical visits) were observed at the end of trial. Additionally, there were substantial improvements in productivity, including a reduction in the number of LWDE following pregabalin treatment (?18.9 [26.0]; P < 0.0001). These changes correlated with substantial reductions in both direct (?652.9 ± 1622.4 €; P < 0.0001) and indirect healthcare costs (?851.6 [1259.6] €; P < 0.0001). Conclusions: The cost of care in patients with gabapentin‐refractory peripheral neuropathic pain appeared to be significantly reduced after switching to pregabalin treatment, alone or in combination with other analgesic drugs, in a real‐life setting.     

Predictors of pain medication selection among patients diagnosed with fibromyalgia

Objectives: Several pharmacologic therapies have been recommended for managing fibromyalgia. However, the factors associated with each treatment initiation have not been well established. This study assessed factors that were associated with the use of duloxetine vs. other pain medications among patients with fibromyalgia. Research Design and Methods: Administrative claims from a large, U.S. commercially insured population were analyzed using a retrospective cohort design. Patients with fibromyalgia who were 18 to 64 years old and initiated duloxetine vs. selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), venlafaxine, gabapentin, pregabalin, tramadol, or nontramadol opioids between January 1, 2007 and December 12, 2008 were selected. Treatment initiation was defined as no access to the same medication over the previous 90 days, with the most recent initiation date as the index date. All patients selected had at least one fibromyalgia diagnosis (ICD‐9‐CM: 729.1) in the 12 months prior to initiation of each study medication. Multiple logistic regression models were estimated to assess the predictors of initiating duloxetine vs. each of the other medications. Results: The study included 117,305 patients with fibromyalgia (48 years of age on average; 76% women) who initiated duloxetine (n = 5,827), SSRIs (n = 8,620), TCAs (n = 5,424), venlafaxine (n = 2,038), gabapentin (n = 5,733), pregabalin (n = 11,152), tramadol (n = 7,312), or nontramadol opioids (n = 71,199). Common fibromyalgia‐related comorbidities were low back pain (31% to 49%), osteoarthritis (14% to 21%), and sleep disturbance (10% to 15%). Controlling for demographic and clinical characteristics, patients who received pregabalin in the prior 12‐month period were more likely to initiate duloxetine. Patients from other treatment cohorts, except for those in the pregabalin and nontramadol opioid cohorts, were more likely to re‐initiate the same prior medication than to begin treatment with duloxetine. Other predictors of duloxetine initiation included history of rheumatoid and sleep disturbance. Conclusions: The presence of select comorbidities and prior use of certain medications were associated with the duloxetine initiation among working‐age, commercially insured patients with fibromyalgia.