What is the recommended workup and treatment for fibromyalgia?

Fibromyalgia Workup and Treatment

The recommended workup for fibromyalgia should focus on clinical diagnostic criteria while the treatment should prioritize non-pharmacological approaches first, followed by FDA-approved medications such as pregabalin, duloxetine, or milnacipran based on predominant symptoms. 1

Diagnostic Workup

Clinical Diagnostic Criteria

• Use the American College of Rheumatology (ACR) criteria for diagnosis:
  • History of widespread pain present for at least 3 months
  • Pain upon digital pressure in at least 11 of the 18 tender points
  • Pressure of approximately 4 kg 1

Screening Tools

• Consider using the Fibromyalgia Rapid Screening Tool for patients with diffuse chronic pain 2

Rule Out Other Conditions

• Evaluate for comorbid conditions that frequently occur with fibromyalgia:
  • Inflammatory arthritis
  • Other rheumatologic conditions
  • Psychiatric disorders (depression, anxiety)
  • Functional somatic syndromes 2

Treatment Approach

First-Line: Non-Pharmacological Therapies

1. Exercise Therapy 1

   • Aerobic exercise and strength training: 2-3 sessions/week, 10-30 minutes per session
   • Start with low intensity and gradually increase
   • Focus on improving function and reducing symptoms

2. Cognitive Behavioral Therapy (CBT) 1

   • Typically 8-12 weekly sessions
   • Addresses pain catastrophizing and improves coping strategies

3. Patient Education 1, 2

   • Explain central sensitization mechanism
   • Set realistic expectations for symptom management
   • Emphasize self-management strategies

4. Additional Non-Pharmacological Options

   • Heated pool treatment/hydrotherapy 1
   • Mindfulness-based stress reduction 1
   • Meditative movement (yoga, tai chi, qigong) 1
   • Mediterranean-style diet 1

Second-Line: Pharmacological Treatment

FDA-Approved Medications

1. Pregabalin 1, 3

   • Starting dose: 75 mg twice daily (150 mg/day)
   • May increase to 300 mg/day within 1 week
   • Maximum recommended dose: 450 mg/day
   • Particularly effective for pain and sleep disorders
   • Note: Although studied at 600 mg/day, no additional benefit was observed, and this dose was less well tolerated 3

2. Duloxetine 1, 4

   • Starting dose: 30 mg once daily for 1 week
   • Target dose: 60 mg once daily
   • Particularly effective when fibromyalgia is comorbid with depression or anxiety
   • Note: No evidence that doses greater than 60 mg/day confer additional benefit 4

3. Milnacipran 1, 5

   • FDA-approved for fibromyalgia
   • Effective for pain and fatigue symptoms
   • Particularly useful when comorbid with depression or anxiety

4. Amitriptyline 1

   • 10-25 mg at bedtime
   • Effective for pain and sleep disorders
   • Use with caution in older adults

Other Medication Considerations

• Cyclobenzaprine: May be considered for pain and sleep disturbances 1
• Tramadol: May be considered for severe pain, but use cautiously due to risk of dependence 1

Medications to Avoid

• NSAIDs: Not recommended due to lack of efficacy 1, 2
• Strong opioids: Not recommended due to lack of efficacy and potential for harm 1, 2
• Corticosteroids: Not recommended due to lack of efficacy and potential for harm 1
• Cannabis: Not recommended as first-line treatment due to limited and inconsistent evidence 1

Special Population Considerations

Pregnant Patients

• Focus on non-pharmacological approaches 1

Elderly Patients

• Use lower initial doses of medications with gradual titration 1

Patients with Comorbid Conditions

• Continue disease-modifying treatments for inflammatory arthritis while addressing fibromyalgia symptoms separately 1
• For patients with renal impairment, consider lower starting doses of medications like pregabalin 3

Treatment Algorithm

1. Establish diagnosis using ACR criteria
2. Begin with non-pharmacological therapies:
   • Exercise therapy
   • Cognitive behavioral therapy
   • Patient education
3. If inadequate response, add pharmacological therapy based on predominant symptoms:
   • For pain and sleep issues: Pregabalin or amitriptyline
   • For pain with comorbid depression/anxiety: Duloxetine or milnacipran
4. Reassess regularly for treatment response and adjust as needed
5. Consider combination therapy for patients with inadequate response to single modalities

Common Pitfalls to Avoid

• Relying solely on pharmacological treatments
• Using opioids or NSAIDs as primary treatment
• Failing to address sleep disturbances and mood disorders
• Ordering excessive diagnostic testing after diagnosis is established
• Not setting realistic expectations with patients about symptom management