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Updated October 2023
Milnacipran (brand name: Joncia®) belongs to a class of medicines called serotonin and noradrenaline reuptake inhibitors (SNRI). Other similar drugs from this group are used to treat depression and anxiety, but in Australia milnacipran is approved specifically to treat fibromyalgia.
Although milnacirpan is not listed on the Pharmaceutical Benefits Scheme (PBS), your rheumatologist may be able to obtain approval through the Special Access Scheme and prescribe it.
The purpose of taking medications in fibromyalgia is to control symptoms and improve quality of life. Medications in fibromyalgia should be used as part of a treatment plan together with non-medication approaches, such as physical activity.
Milnacipran has been studied in over 3000 fibromyalgia patients worldwide. In clinical studies that compared milnacipran to placebo, milnacipran improved the symptoms of pain, fatigue, sleep quality and quality of life.
Milnacipran can additionally have mild positive effects on disability and cognition (clarity of thinking).
Milnacipran is taken orally twice daily. It currently comes in capsules of two strengths: 25mg and 50mg.
To minimise side effects, it is recommended to commence with a single daily dose of 25mg for two days, then increase to 25mg twice daily for six days before increasing to the full dose of 50mg twice daily.
If after six days on 25mg twice daily side effects are occurring, it is recommended that the 25mg twice daily dosage be continued for another 7 days as there is a reasonable chance side effects will settle during this extra time on the lower dose.
In general, if no useful response occurs within 4 weeks of taking the full dose of milnacipran it should be ceased. Drug cessation should occur by weaning over at least 2 weeks. Do not stop milnacipran suddenly.
As milnacipran increases serotonin levels within the brain, if it is taken together with other medications which also increase serotonin it may cause the serotonin syndrome, a potentially serious medical condition. These medications include tramadol, triptan medications for migraine and most antidepressants, such as amitriptyline, escitalopram and St John’s wort. In general, milnacipran should not be taken concurrently with any of these.
Milnacipran works by an independent mechanism in the brain and so does not interact with pregabalin, allowing it to be safely taken at the same time. Similarly, pain relievers such as paracetamol and non-steroidal anti-inflammatories (such as Nurofen™) do not interact with milnacipran.
Treatment with milnacipran is continued indefinitely as long as it is effective and as long as no serious side effects occur. The beneficial effect does not tend to wear off.
If you stop milnacipran treatment for more than a few weeks there is a risk that your condition may worsen. Continue with your treatment unless advised by your doctor or unless side effects develop.
You might experience side effects with your treatment. Tell your doctor if you are concerned about possible side effects.
Most people with fibromyalgia experience at least one side effect from milnacipran, but only a minority of these people will stop the drug because of persistent side effects.
Although the effectiveness of milnacipran may be mildly improved by increasing the dose above 50mg twice daily to a maximum of 100mg twice daily, significant side effects occur more frequently.
A reduction in dose may minimise side effects so that you can continue to take the treatment. Your doctor will advise on any dose changes that are necessary.
Nausea, constipation, hot flushes, headaches and excessive sweating are the most common side effects of milnacipran.
Less common side effects include dizziness, palpitations, high blood pressure and increased heart rate.
Information that comes with your milnacipran medicine describes in detail potential side effects that may occur with milnacipran.
In general, milnacipran should not be used in people who have:
In addition, before starting milnacipran, you should tell your doctor if you have any of the following:
If these conditions are well controlled, it may still be possible to cautiously take milnacipran.
Both before and during treatment with milnacipran, blood pressure and heart rate should be regularly monitored.
Although there is no evidence of interaction with alcohol, as milnacipran has an effect on the brain, alcohol should only be consumed in moderation while taking it.
Milnacipran should not be used during pregnancy or breastfeeding.
Store milnacipran in a cool, dry place, away from direct heat and light (e.g. not in the bathroom).
Keep all medicines out of reach of children.