TOPLINE:

In adults with moderate-to-severe fibromyalgia, duloxetine 120 mg offered greater quality-adjusted life-years (QALYs) and lower costs than amitriptyline. Pregabalin 450 mg also showed cost benefits over amitriptyline but was less effective than duloxetine 120 mg.

METHODOLOGY:

• Researchers used a Markov cohort state-transition model to evaluate the cost-effectiveness of pharmacologic treatments for fibromyalgia.
• The simulated cohort included adults with moderate-to-severe fibromyalgia (mean age, 48.4 years; 94.4% women), and the analysis was conducted from both US healthcare payer and societal perspectives.
• Four pharmacologic interventions were analyzed — amitriptyline, pregabalin, duloxetine, and milnacipran — with various dosages.
• The health states comprised mild, moderate, severe, and death, and the transition probabilities between these states were derived from a Bayesian network meta-analysis of 36 randomized clinical trials.
• Data on drug acquisition costs and other costs, including direct and indirect costs, were obtained from the Red Book and published studies on the economic burden of fibromyalgia. Expected lifetime costs and QALYs were estimated for each pharmacologic strategy.

TAKEAWAY:

• Duloxetine 120 mg and amitriptyline were on the efficient frontier, with duloxetine offering more QALYs at a slightly higher cost than amitriptyline (10.40 vs 9.99 QALYs and $115,770 vs $115,145).
• From a societal perspective, duloxetine 120 mg was the most cost-effective, providing the highest QALYs at the lowest lifetime cost.
• Pregabalin 450 mg showed lower costs and greater QALYs than amitriptyline, with an incremental net monetary benefit of $40,190 relative to amitriptyline at a willingness-to-pay threshold of $100,000.
• Probabilistic sensitivity analysis showed that duloxetine 120 mg had the highest probability of being cost-effective across most willingness-to-pay thresholds from the US healthcare payer perspective. It also had the highest probability of being cost-effective (reaching only 45% at $100,000 per QALY) from the US societal perspective. No strategy exceeded a 60% probability of being cost-effective.

IN PRACTICE:

“This analysis demonstrates that optimal [fibromyalgia] treatment from an economic perspective differs from current prescribing patterns and formulary designs,” the authors wrote. “[The study] findings suggest that duloxetine 120 mg offers the greatest economic value for this patient population while highlighting the importance of accounting for societal costs in fibromyalgia treatment decisions. Clinical decisions should additionally consider adverse event profiles, patient comorbidities, and expected variability in treatment response,” they added.

SOURCE:

This study was led by Sarah S. Downen, PharmD, MS, University of Florida, Gainesville, Florida. It was published online on February 3, 2026, in JAMA Network Open.

LIMITATIONS:

The utility values derived from quality-of-life instruments used in the study may not fully reflect cognitive dysfunction, fatigue, and subtle psychological changes. Cost estimates may not account for regional variations in healthcare prices. The analysis did not address individual patient variability in treatment response.

DISCLOSURES:

No funding information or conflicts of interest were reported by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.