What is the step-wise approach to treating fibromyalgia?

From the Guidelines

The treatment of fibromyalgia should follow a stepwise, multimodal approach, starting with non-pharmacological interventions as the foundation, and prioritizing aerobic exercise, strength training, and cognitive behavioral therapy, as recommended by the most recent and highest quality study 1.

Step-wise Approach to Treating Fibromyalgia

The approach to treating fibromyalgia involves several key components:

• Non-pharmacological interventions: These should be the foundation of treatment, including:
  • Aerobic exercise: starting with 5-10 minutes daily and gradually increasing to 30 minutes 3-4 times weekly
  • Strength training
  • Cognitive behavioral therapy (8-12 sessions) to develop pain coping strategies and address maladaptive thoughts
  • Sleep hygiene: consistent sleep schedules, avoiding stimulants before bedtime, and creating a comfortable sleep environment
• Pharmacological treatments: If non-pharmacological interventions provide insufficient relief, add pharmacological treatments starting with:
  • Amitriptyline (10-25 mg at bedtime)
  • Duloxetine (30-60 mg daily)
  • Milnacipran (50-100 mg twice daily)
  • Pregabalin (150-450 mg daily in divided doses) or gabapentin (300-1200 mg three times daily) for persistent pain
• Complementary approaches: Acupuncture, tai chi, yoga, and mindfulness meditation can supplement the treatment plan.

Key Considerations

• Avoid opioids as they can worsen symptoms long-term 1
• Consider patient preferences and comorbidities when selecting treatments
• A multidisciplinary approach, including a combination of non-pharmacological and pharmacological treatment modalities, is often necessary to manage fibromyalgia effectively 1

Evidence-based Recommendations

The recommendations are based on the most recent and highest quality studies, including the 2022 Mayo Clinic Proceedings study 1 and the 2022 MMWR Recommendations and Reports study 1, which provide evidence for the effectiveness of non-pharmacological and pharmacological interventions in managing fibromyalgia. The 2017 Annals of the Rheumatic Diseases study 1 also provides guidance on the management of fibromyalgia, emphasizing the importance of a graduated approach and a multidisciplinary team.

From the FDA Drug Label

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 step-wise approach to treating fibromyalgia with duloxetine is:

• Start with a dose of 30 mg once daily for 1 week
• Increase to 60 mg once daily The step-wise approach to treating fibromyalgia with pregabalin is:
• Titrate during a 6-week open-label dose optimization phase to a total daily dose of 300 mg, 450 mg, or 600 mg
• Patients were considered to be responders if they had both: 1) at least a 50% reduction in pain (VAS) and, 2) rated their overall improvement on the PGIC as "much improved" or "very much improved" Note: The FDA label does not provide a step-wise approach for treating fibromyalgia in general, but rather for specific medications. 2, 2, 3

From the Research

Step-wise Approach to Treating Fibromyalgia

The treatment of fibromyalgia requires a multidisciplinary approach, incorporating both pharmacological and non-pharmacological therapies. The following steps can be considered:

• Non-pharmacological interventions: Recommended as the first line of treatment, these include:
  • Aerobic exercise
  • Cognitive behavioral therapy
  • Patient education
  • Physical activity, such as strength training 4, 5, 6
• Pharmacological therapy: Medications can be used to promote pain modulation, including:
  • Antidepressants (e.g., duloxetine, milnacipran, amitriptyline) 4, 5, 6
  • Antiepileptic drugs (e.g., pregabalin) 4, 5, 6
  • Calcium-channel modulators
  • Muscle relaxants
  • Analgesics 7
• Alternative and complementary therapies: These may be considered for patients who do not respond to traditional treatments, including:
  • Digital health interventions
  • Combined treatments
  • Non-invasive neuromodulation
  • Medical cannabis and nutraceuticals (although more data is needed to prove their efficacy) 4, 6
• Multidisciplinary approach: A combination of therapies, including non-pharmacological and pharmacological interventions, is often the most effective strategy for managing symptoms in patients with fibromyalgia 4, 5, 6

Key Considerations

• Patient education and reassurance can help decrease unnecessary testing and improve outcomes 5
• A step-wise approach, starting with non-pharmacological interventions and adding pharmacological therapies as needed, can be effective in managing fibromyalgia symptoms 7, 4, 5, 8, 6
• Regular follow-up and monitoring of treatment response can help adjust the treatment plan as needed 4, 5, 6