What is the recommended treatment for fibromyalgia?

From the Guidelines

The recommended treatment for fibromyalgia involves a multifaceted approach 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 suggested by the most recent guidelines 1.

Key Components of Treatment

• Medications:
  • FDA-approved options such as duloxetine (Cymbalta) 30-60mg daily, milnacipran (Savella) 50mg twice daily, or pregabalin (Lyrica) 150-450mg daily divided into multiple doses
  • Other medications that may help include amitriptyline 10-25mg at bedtime, cyclobenzaprine 5-10mg at bedtime for muscle relaxation, or tramadol 50-100mg every 4-6 hours as needed for pain
• Non-pharmacological management:
  • Aerobic and strengthening exercise, with a strong recommendation for its use 1
  • Cognitive behavioral therapies, with a weak recommendation for its use 1
  • Multicomponent therapies, with a weak recommendation for its use 1
  • Defined physical therapies: acupuncture or hydrotherapy, with a weak recommendation for its use 1
  • Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction, with a weak recommendation for its use 1

Lifestyle Modifications

• Regular moderate exercise, starting with 5-10 minutes daily and gradually increasing to 30 minutes most days
• Physical therapy focusing on gentle stretching and strengthening exercises to improve function
• Sleep hygiene practices are essential as poor sleep worsens symptoms
• Stress reduction techniques like meditation, deep breathing, or yoga can help manage flare-ups

Treatment Approach

• Optimal management requires prompt diagnosis and a comprehensive assessment of pain, function, and psychosocial context
• Management should aim at improving health-related quality of life, balancing benefit and risk of treatment, and often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features, and patient preferences and comorbidities
• Initial management should focus on non-pharmacological therapies, with pharmacological therapy added as needed, as suggested by the guidelines 1

From the FDA Drug Label

1. 5 Management of Fibromyalgia in Adults

The recommended dose of pregabalin for fibromyalgia is 300 to 450 mg/day. Begin dosing at 75 mg two times a day (150 mg/day). The dose may be increased to 150 mg two times a day (300 mg/day) within 1 week based on efficacy and tolerability Patients who do not experience sufficient benefit with 300 mg/day may be further increased to 225 mg two times a day (450 mg/day). Although pregabalin was also studied at 600 mg/day, there is no evidence that this dose confers additional benefit and this dose was less well tolerated In view of the dose-dependent adverse reactions, treatment with doses above 450 mg/day is not recommended [see ADVERSE REACTIONS (6.1)].

Recommended Treatment for Fibromyalgia:

• Pregabalin: 300 to 450 mg/day, starting at 75 mg two times a day (150 mg/day)
• Duloxetine: 60 mg once daily, starting at 30 mg once daily for 1 week The dosage may be adjusted based on efficacy and tolerability. It is essential to follow the recommended dosage and administration guidelines to minimize the risk of adverse reactions. 2 3

From the Research

Fibromyalgia Treatment Options

Fibromyalgia is a chronic pain disorder with unclear etiology, and no definitive treatment is available. However, various medications can be used for symptom management.

• The most commonly used medications for fibromyalgia include:
  • Amitriptyline, an antidepressant that can help with pain relief and sleep quality 4
  • Pregabalin, an anticonvulsant that has analgesic, anticonvulsant, and anxiolytic activity 5, 6
  • Duloxetine, an antidepressant that can help with pain relief, sleep quality, and quality of life 5, 7
  • Gabapentin, an anticonvulsant that can help with pain relief 8
  • Milnacipran, an antidepressant that can help with pain relief, fatigue, and sleep quality 7

Combination Therapy

Combination therapy, such as combining pregabalin with duloxetine, may be more effective than monotherapy in improving multiple clinical outcomes, including pain relief, sleep quality, and quality of life 5.

Treatment Efficacy

The efficacy of these medications can vary depending on the individual patient and the specific symptoms being treated.

• Amitriptyline has been shown to have some benefit in reducing pain, but the evidence is limited and of low quality 4
• Pregabalin has been shown to be effective in reducing pain, improving sleep quality, and improving quality of life 5, 6
• Duloxetine has been shown to be effective in reducing pain, improving sleep quality, and improving quality of life 5, 7
• Gabapentin has been shown to be effective in reducing pain, but the evidence is limited 8
• Milnacipran has been shown to be effective in reducing pain, improving sleep quality, and improving quality of life, particularly in patients with fatigue 7

Adverse Events

All of these medications can have adverse events, including:

• Nausea and dizziness with duloxetine 7
• Drowsiness with pregabalin and duloxetine combination therapy 5
• Adverse events such as dry mouth, constipation, and dizziness with amitriptyline 4