From the Guidelines
The first-line treatment for fibromyalgia syndrome (FMS) should focus on non-pharmacological therapies, including aerobic and strengthening exercise, cognitive behavioral therapies, and multicomponent therapies, as recommended by the 2017 EULAR revised recommendations for the management of fibromyalgia 1. The management of fibromyalgia 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. Some key non-pharmacological interventions include:
- Aerobic and strengthening exercise, which has a strong recommendation for improving symptoms in patients with fibromyalgia 1
- Cognitive behavioral therapies, which can help address maladaptive thought patterns and develop coping strategies for pain management 1
- Multicomponent therapies, which can provide a comprehensive approach to managing fibromyalgia symptoms 1 Pharmacological management may be considered as an adjunct to non-pharmacological therapies, with options including:
- Amitriptyline, duloxetine, or milnacipran, which have been shown to be effective in improving pain and function in patients with fibromyalgia 1
- Pregabalin, which has been FDA-approved for the treatment of fibromyalgia and can help improve pain, function, and quality of life 1 It's essential to note that the treatment response varies individually, and the goal is improvement in function and quality of life rather than complete pain elimination. The most recent and highest quality study, the 2022 CDC clinical practice guideline for prescribing opioids for pain, also recommends a multimodal approach for managing fibromyalgia, including non-pharmacological and pharmacological interventions 1.
From the FDA Drug Label
The efficacy of pregabalin for management of fibromyalgia was established in one 14-week, double-blind, placebo-controlled, multicenter study (F1) and one six-month, randomized withdrawal study (F2) 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 In addition, improvement was demonstrated based on a patient global assessment (PGIC), and on the Fibromyalgia Impact Questionnaire (FIQ).
The first-line treatment for a patient diagnosed with fibromyalgia is pregabalin.
- Key points:
- Pregabalin has been shown to reduce pain in patients with fibromyalgia.
- Improvement was also demonstrated based on patient global assessment and the Fibromyalgia Impact Questionnaire.
- The recommended dosage is 300 mg, 450 mg, or 600 mg per day. 2
From the Research
First-Line Treatment for Fibromyalgia
The first-line treatment for a patient diagnosed with fibromyalgia should focus on nonpharmacological interventions, as recommended by recent studies 3, 4.
Nonpharmacological Interventions
These interventions include:
- Aerobic exercise
- Cognitive behavioral therapy
- Patient education
- Multidisciplinary modality
- Balneotherapy
- Massage
These approaches have been shown to improve symptoms, function, and well-being in patients with fibromyalgia 5, 3, 4, 6.
Individualized Treatment
It is essential to individualize treatment according to the predominant symptom, as different interventions may be more effective for specific symptoms, such as:
- Exercise for pain and depression
- Mind-body and strengthening exercises for fatigue
- Aerobic and strengthening exercises for sleep
- Psychological treatments, including cognitive behavioral therapy and mindfulness, for pain, sleep, and depression 3.
Pharmacological Therapy
While nonpharmacological interventions are recommended as the first line of treatment, pharmacological therapy may be considered in conjunction with these approaches. Medications approved by the FDA for the treatment of fibromyalgia include duloxetine, milnacipran, and pregabalin 7, 4.
Combination Therapy
Combination therapy, incorporating both nonpharmacological and pharmacological interventions, may be the most effective strategy for managing symptoms in patients with fibromyalgia 7, 4, 6.