From the Guidelines
The recommended treatment approach for fibromyalgia pain involves a multimodal strategy combining medication, physical therapy, and lifestyle modifications, with a focus on improving health-related quality of life and balancing benefit and risk of treatment, as recommended by the 2017 EULAR revised recommendations for the management of fibromyalgia 1.
Key Components of Treatment
- Medications:
- First-line medications include duloxetine (Cymbalta) 30-60mg daily, milnacipran (Savella) 50mg twice daily, or pregabalin (Lyrica) 150-450mg daily divided into multiple doses, as supported by the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
- Amitriptyline 10-25mg at bedtime may also be effective, as suggested by the 2022 Mayo Clinic Proceedings guideline for the management of chronic multisymptom illness 1.
- Physical therapy:
- Gradual, progressive exercise starting with low-impact activities like walking or swimming for 20-30 minutes, 2-3 times weekly, gradually increasing duration and intensity, as recommended by the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
- Lifestyle modifications:
- Cognitive behavioral therapy (8-12 sessions) to develop pain coping strategies, as suggested by the 2022 Mayo Clinic Proceedings guideline for the management of chronic multisymptom illness 1.
- Sleep hygiene improvements, as poor sleep worsens pain.
- Stress reduction techniques such as meditation, deep breathing, or yoga practiced daily for 10-15 minutes to help manage pain flares.
Prioritizing Treatment
The treatment approach should prioritize the individual patient's needs, preferences, and comorbidities, with a focus on improving health-related quality of life and balancing benefit and risk of treatment, as recommended by the 2017 EULAR revised recommendations for the management of fibromyalgia 1.
Evidence-Based Recommendations
The recommended treatment approach is based on the highest quality evidence available, including the 2017 EULAR revised recommendations for the management of fibromyalgia 1, the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1, and the 2022 Mayo Clinic Proceedings guideline for the management of chronic multisymptom illness 1.
Multidisciplinary Approach
A multidisciplinary approach, including non-pharmacological and pharmacological treatment modalities, is recommended to manage fibromyalgia, as suggested by the 2022 CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
Patient-Centered Care
Patient-centered care, including shared decision-making with the patient, is essential to develop an individualized treatment plan that addresses the patient's unique needs and preferences, as recommended by the 2017 EULAR revised recommendations for the management of fibromyalgia 1.
From the FDA Drug Label
The efficacy of duloxetine delayed-release capsules for the management of fibromyalgia in adults was established in two randomized, double-blind, placebo-controlled, fixed-dose trials in adult patients meeting the American College of Rheumatology criteria for fibromyalgia The recommended duloxetine delayed-release capsules dosage is 60 mg once daily in adults with fibromyalgia. Begin treatment at 30 mg once daily for 1 week, to allow patients to adjust to duloxetine delayed-release capsules before increasing to 60 mg once daily. Studies F1 and F2 enrolled patients with a diagnosis of fibromyalgia using the American College of Rheumatology (ACR) criteria (history of widespread pain for 3 months, and pain present at 11 or more of the 18 specific tender point sites). The studies showed a reduction in pain by visual analog scale
The recommended treatment approach for fibromyalgia pain is:
- Duloxetine: 60 mg once daily, starting with 30 mg once daily for 1 week
- Pregabalin: 300 mg, 450 mg, or 600 mg daily, with evidence of dose-dependent adverse reactions Key points:
- Duloxetine and pregabalin have been shown to be effective in reducing pain in patients with fibromyalgia
- The recommended dosage for duloxetine is 60 mg once daily, while pregabalin can be dosed at 300 mg, 450 mg, or 600 mg daily
- Patients should be started on a lower dose and gradually increased as needed and tolerated 2, 2, 3
From the Research
Treatment Approaches for Fibromyalgia Pain
The treatment of fibromyalgia pain typically involves a combination of medication and non-pharmacologic therapies. Some of the commonly used medications for fibromyalgia pain management include:
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregabalin
Medication Use Patterns
Studies have shown that patients with fibromyalgia often have multiple comorbidities and use various medications, including opioids, benzodiazepines, sleep disorder drugs, and muscle relaxants 4. The median daily dose of these medications can vary, and the treatment duration is often short, with only one-fifth of patients continuing treatment for more than a year.
Combination Therapy
Combination therapy, such as the use of pregabalin and duloxetine, has been shown to be effective in improving multiple clinical outcomes, including pain reduction, global pain relief, and sleep quality 5. This approach may be beneficial for patients who do not respond to monotherapy.
Non-Pharmacologic Therapies
Non-pharmacologic therapies, such as exercise, warm-water therapy, and psychological pain management techniques, can also be effective in managing fibromyalgia symptoms 6. These therapies can be used in conjunction with medication to provide comprehensive pain management.
Comparative Efficacy of Medications
Studies have compared the efficacy of different medications, including amitriptyline, duloxetine, and pregabalin, in reducing pain intensity in patients with fibromyalgia 7, 8. The results suggest that duloxetine may be more effective than pregabalin in reducing pain, while amitriptyline may be more effective in reducing pain intensity by 50%.
Key Findings
Some key findings from the studies include:
- Duloxetine and pregabalin are commonly used medications for fibromyalgia pain management
- Combination therapy may be beneficial for patients who do not respond to monotherapy
- Non-pharmacologic therapies can be effective in managing fibromyalgia symptoms
- The efficacy of medications can vary, and individual patient responses may differ 4, 5, 6, 7, 8