From the Guidelines
Fibromyalgia diagnosis and treatment should prioritize a multimodal approach, combining non-pharmacological and pharmacological therapies tailored to the individual patient's needs, as recommended by the 2017 EULAR revised recommendations 1. The diagnostic criteria for fibromyalgia involve widespread pain lasting at least 3 months, accompanied by symptoms like fatigue, cognitive difficulties, and unrefreshing sleep.
Key Diagnostic Considerations
- Widespread pain index (WPI) score of at least 7 and symptom severity scale (SSS) score of at least 5, or WPI of 4-6 with SSS of at least 9.
- Comprehensive assessment of pain, function, and psychosocial context is essential for optimal management.
Treatment Options
- Non-pharmacological management: Aerobic and strengthening exercise, cognitive behavioral therapies, multicomponent therapies, defined physical therapies (acupuncture or hydrotherapy), and meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction are recommended 1.
- Pharmacological management: Amitriptyline (at low dose), duloxetine, milnacipran, tramadol, pregabalin, and cyclobenzaprine are recommended, with the choice of medication depending on the individual patient's needs and preferences 1.
Important Considerations
- Treatment should be individualized, with regular follow-up to adjust therapies based on response.
- Patient education about the condition's nature is essential, emphasizing that while fibromyalgia is chronic, symptoms can be managed effectively.
- The 2017 EULAR revised recommendations 1 provide the most up-to-date guidance on the diagnosis and treatment of fibromyalgia, superseding earlier recommendations such as the 2008 EULAR evidence-based recommendations 1.
From the FDA Drug Label
The studies showed a reduction in pain by visual analog scale In addition, improvement was demonstrated based on a patient global assessment (PGIC), and on the Fibromyalgia Impact Questionnaire (FIQ). The patients had 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 diagnostic criteria for fibromyalgia include:
- A history of widespread pain for 3 months
- Pain present at 11 or more of the 18 specific tender point sites, as defined by the American College of Rheumatology (ACR) criteria. The treatment options for fibromyalgia include:
- Pregabalin: total daily doses of 300 mg, 450 mg and 600 mg
- Duloxetine: 60 mg once daily or 120 mg daily (given in divided doses) 2 3
From the Research
Diagnostic Criteria for Fibromyalgia
- The American College of Rheumatology (ACR) published diagnostic research criteria for fibromyalgia in 1990, which included a history of chronic and widespread pain and the presence of 11 or more out of 18 tender points 4.
- However, the focus on tender points was later found to be not justified, and new preliminary ACR diagnostic criteria were developed in 2010, which included a widespread pain index (WPI) and categorical scales for cognitive symptoms, un-refreshed sleep, fatigue, and number of somatic symptoms 4.
- The diagnostic criteria for fibromyalgia have been refined over time, and the current criteria include a combination of the WPI and symptom severity (SS) scale, with a recommended case definition of fibromyalgia: (WPI > or = 7 AND SS > or = 5) 4.
Treatment Options for Fibromyalgia
- There is no known cure for fibromyalgia, but multidisciplinary team efforts using combined treatment approaches, including patient education, aerobic exercise, cognitive behavioral therapy, and pharmacologic therapies, may improve symptoms and function in patients with fibromyalgia 4.
- Pharmacologic therapies, such as serotonin norepinephrine reuptake inhibitors (e.g., duloxetine, milnacipran) and alpha 2-delta receptor ligands (e.g., pregabalin), have been shown to be effective in treating fibromyalgia symptoms 4, 5.
- Nonpharmacologic treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can also be helpful in managing fibromyalgia symptoms 6, 5.
Challenges in Diagnosing Fibromyalgia
- Fibromyalgia can be difficult to diagnose due to its wide range of symptoms and common comorbidities, and there is no "gold standard" for diagnosing the condition 7, 8.
- The diagnosis of fibromyalgia requires a careful history and evaluation, and clinicians should be aware of the limitations inherent in using tender points in the diagnosis of fibromyalgia 7.
- Screening questions based on published criteria can be used as a first approach in diagnosing functional illnesses, including fibromyalgia 7.