OBJECTIVES: To compare health care utilization between duloxetine initiators and pregabalin initiators among fibromyalgia patients in a real-world setting. METHODS: A retrospective cohort study was conducted based on a US national commercial health claims database (2006-2009).  Fibromyalgia patients who initiated duloxetine or pregabalin in 2008, age 18 to 64, and maintained continuous health insurance coverage one year before and one year after initiation were assigned to duloxetine or pregabalin cohorts based on their initiated agent. Patients who had pill coverage of the agents over 90 days preceding the initiation were excluded. The two comparative cohorts were constructed using propensity score greedy match approach. Descriptive analysis and paired-t test were performed to compare fibromyalgia-related health care utilization rates (inpatient, outpatient, medication) in the one-year post-initiation period between the two matched cohorts. RESULTS: Both matched cohorts (n = 1,265 pairs) had a similar mean initiation age (49-50 years), female percentage (87-88%), and baseline co-morbid conditions (neuropathic pain other than diabetic peripheral neuropathic pain, low back pain, cardiovascular disease, hypertension, headache or migraine and osteoarthritis). In the year preceding the initiation, both cohorts had similar inpatient utilization rates (15.7-16.1%), outpatient utilization rates (100%) and medication utilization rates (97.9-98.7%). In the post-initiation year, the utilization rates were different between the cohorts with the pregabalin cohort using more fibromyalgia related inpatient care (3.2% vs. 2.2%, p<0.05), all inpatient care (19.3% vs. 16.8%, p<0.05), fibromyalgia related outpatient care (62.1% vs. 51.8%, p<0.05), selective serotonin reuptake inhibitors (34.0% vs. 20.1%, p<0.05) and other fibromyalgia related medications, including antidepressants and anticonvulsants other than duloxetine or pregabalin. CONCLUSIONS: Compared to fibromyalgia patients who initiated duloxetine, fibromyalgia patients who initiated pregabalin consumed more fibromyalgia-related inpatient, outpatient, and medication care in the first post-initiation year.