What is the recommended management plan for patients with fibromyalgia?

Management of Fibromyalgia

The recommended management plan for fibromyalgia should begin with non-pharmacological therapies as first-line treatment, particularly exercise therapy, followed by pharmacological options only if insufficient response is achieved. 1

Diagnosis

Before initiating treatment, confirm diagnosis using:

• American College of Rheumatology criteria
• Widespread pain index (WPI) and symptom severity scale (SS)
• Limited laboratory testing only to exclude treatable comorbidities

Non-Pharmacological Therapies (First-Line)

Exercise Therapy

• Start with individualized graded physical exercise (strongest evidence base) 2, 1
• Aerobic exercise and strength training: 2-3 sessions/week, 10-30 minutes per session
• Begin with low intensity and gradually increase
• Focus on improving function and reducing symptoms

Psychological Approaches

• Cognitive Behavioral Therapy (CBT): 8-12 weekly sessions to address pain catastrophizing and improve coping strategies 1
• Mindfulness-based stress reduction and relaxation techniques

Additional Non-Pharmacological Options

• Heated pool treatment/hydrotherapy 1
• Meditative movement (yoga, tai chi, qigong)
• Mediterranean-style diet emphasizing vegetables, fruits, whole grains, and limiting processed foods 1

Pharmacological Therapies (If Non-Pharmacological Approaches Insufficient)

First-Line Medications

1. Duloxetine (SNRI):

   • Start at 30 mg once daily for 1 week
   • Target dose: 60 mg once daily
   • Particularly effective when fibromyalgia is comorbid with depression or anxiety 1, 3

2. Pregabalin:

   • Start at 75 mg twice daily
   • Target dose: 300-450 mg/day (divided doses)
   • Maximum recommended dose: 450 mg/day
   • Particularly effective for pain and sleep disorders 1, 4

3. Amitriptyline:

   • Start at 10-25 mg at bedtime
   • Use with caution in older adults 1

4. Milnacipran (SNRI):

   • FDA-approved for fibromyalgia
   • Effective for pain and function 1, 5

Second-Line Medications

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

Medications to Avoid

• NSAIDs: Limited efficacy for fibromyalgia 1, 5
• Strong opioids: Not recommended due to lack of efficacy and potential for harm 1
• Corticosteroids: Not recommended 1

Special Considerations

Comorbid Conditions

• Inflammatory arthritis: Continue disease-modifying treatments while addressing fibromyalgia symptoms separately 1
• Pregnancy: Focus on non-pharmacological approaches 1
• Elderly patients: Use lower initial doses of medications with gradual titration 1

Alternative Therapies

• Cannabis is not recommended as first-line treatment due to limited and inconsistent evidence 1
• Should only be considered when conventional treatments have failed

Monitoring and Follow-up

• Regular assessment of:
  • Adherence to exercise program
  • Symptom improvement
  • Need for additional interventions
  • Medication side effects

Treatment Algorithm

1. Start with patient education and non-pharmacological approaches

   • Exercise therapy (most important)
   • CBT and/or mindfulness techniques
   • Hydrotherapy if available

2. If insufficient response after 4-6 weeks, add pharmacological therapy

   • Select based on predominant symptoms:
     • Pain + sleep issues → Pregabalin or amitriptyline
     • Pain + depression/anxiety → Duloxetine or milnacipran

3. If insufficient response after 4-8 weeks of medication

   • Reassess patient to tailor individualized treatment
   • Consider combination therapy or switching medication class

4. For refractory cases

   • Consider multidisciplinary pain clinic referral
   • Evaluate for undiagnosed comorbidities

Remember that while medications can help manage symptoms, they typically provide modest benefits, and the combination of pharmacological and non-pharmacological approaches yields the best outcomes for improving function and quality of life in patients with fibromyalgia 2, 1.