What are the treatment options for a fibromyalgia flare?

From the Guidelines

Treatment for a fibromyalgia flare should prioritize a multidisciplinary approach, combining non-pharmacological and pharmacological therapies tailored to the patient's needs, with a focus on improving health-related quality of life. According to the 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 combination of non-pharmacological and pharmacological treatment modalities.

Some key non-pharmacological management options include:

• Aerobic and strengthening exercise, which has a strong recommendation for improving symptoms 1
• Cognitive behavioural therapies, which have a weak recommendation for 100% of the working group 1
• Multicomponent therapies, defined physical therapies like acupuncture or hydrotherapy, and meditative movement therapies, which all have weak recommendations but are considered beneficial 1

Pharmacological management options include:

• Amitriptyline at low dose, duloxetine, or milnacipran, which all have weak recommendations for 100% of the working group 1
• Pregabalin, which has a weak recommendation for 94% of the working group 1
• Tramadol, which has a weak recommendation for 100% of the working group, although its use should be cautious due to potential for misuse 1

It's essential to note that the use of opioids like tramadol should be approached with caution due to the risk of overdose and addiction, as highlighted in the discussion on the use and misuse of opioids in chronic pain 1. Instead, non-opioid analgesics and other pharmacological options should be considered first-line treatments for fibromyalgia.

In terms of specific treatment regimens, duloxetine (Cymbalta) 30-60mg daily, pregabalin (Lyrica) 75-150mg twice daily, or amitriptyline 10-25mg at bedtime may be beneficial for reducing pain during a flare. Additionally, gentle movement, heat therapy, stress management techniques, good sleep hygiene, and staying hydrated can help reduce flare intensity and improve overall quality of life. These approaches address different aspects of fibromyalgia, including pain processing abnormalities, muscle tension, and inflammatory responses.

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) 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 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 Treatment with duloxetine delayed-release capsules 60 mg or 120 mg daily statistically significantly improved the endpoint mean pain scores from baseline and increased the proportion of patients with at least a 50% reduction in pain score from baseline

Treatment options for fibromyalgia flare 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) Key points:
• Pregabalin and duloxetine have been shown to reduce pain in patients with fibromyalgia
• Improvement was demonstrated based on patient global assessment and Fibromyalgia Impact Questionnaire
• Treatment should be individualized and monitored for efficacy and adverse reactions 2 3

From the Research

Treatment Options for Fibromyalgia Flare

• Fibromyalgia is a syndrome characterized by chronic generalized pain, fatigue, sleep disturbances, stiffness, cognitive impairment, and psychological distress, and its treatment often involves a multidisciplinary approach combining pharmacological and nonpharmacological therapies 4.
• Several drugs are recommended for the treatment of fibromyalgia, including pregabalin, duloxetine, and milnacipran, which are considered the drugs of choice, followed by amitriptyline and cyclobenzaprine 4.
• Other drugs with at least one positive clinical trial for fibromyalgia treatment include selective serotonin reuptake inhibitors, moclobemide, pirlindole, gabapentin, tramadol, tropisetron, sodium oxybate, and nabilone 4.
• A study comparing the effectiveness of duloxetine, pregabalin, and milnacipran in pain management, quality of life, and sleep quality found that all three drugs showed significant improvements, with duloxetine being the most effective in reducing pain and improving sleep and quality of life 5.
• Pregabalin has been shown to be effective in pain management, improving sleep quality and fatigue, as well as in several domains of health-related quality of life, and is considered a well-tolerated therapy for fibromyalgia 6.
• Combination therapy is an option that needs to be more thoroughly investigated in clinical trials, as none of the currently available drugs are fully effective against the whole spectrum of fibromyalgia symptoms 4.
• Clinical characteristics and medication use patterns among fibromyalgia patients newly prescribed amitriptyline, duloxetine, gabapentin, or pregabalin have been studied, and it was found that patients who started one of these drugs had multiple comorbidities and other fibromyalgia-related medication use, but continued the treatment only for a short time 7.
• The role of pharmacological treatments in fibromyalgia has been discussed, and it has been suggested that complex conditions like fibromyalgia may need complex therapies, as drugs that demonstrate a multidimensional effect often fail to demonstrate acceptable efficacy in the majority of the patient population 8.