What is the recommended treatment for fibromyalgia?

Fibromyalgia Treatment

Optimal treatment of fibromyalgia requires a multidisciplinary approach combining pharmacological and non-pharmacological therapies tailored to pain intensity, function, and associated symptoms such as depression, fatigue, and sleep disturbance. 1

Pharmacological Management

First-Line Medications

1. Antidepressants

   • Amitriptyline: Strong evidence (Level Ib, Strength A) for reducing pain and improving function 1

     • Start at 10-25mg at bedtime and gradually titrate to 50-75mg as tolerated 2
     • Monitor for anticholinergic side effects, especially in patients over 65 years

   • Duloxetine: Strong evidence (Level Ib, Strength A) for pain reduction and functional improvement 1

     • Typical starting dose is 30mg daily, increasing to 60mg daily 3
     • Particularly effective when pain is accompanied by depression or anxiety 2

   • Milnacipran: Effective for pain reduction and functional improvement 4

     • Not included in the EULAR guidelines but FDA-approved for fibromyalgia

2. Anticonvulsants

   • Pregabalin: Strong evidence (Level Ib, Strength A) for pain reduction 1
     • Recommended dose for fibromyalgia is 300-450mg/day 5
     • Begin at 75mg twice daily (150mg/day) and increase to 300mg/day within 1 week 5
     • May further increase to 225mg twice daily (450mg/day) if insufficient benefit at 300mg/day 5
     • Doses above 450mg/day are not recommended due to increased adverse effects 5
     • Particularly effective for improving sleep quality 6

3. Analgesics

   • Tramadol: Strong evidence (Level Ib, Strength A) for pain management 1
   • Simple analgesics like acetaminophen and weak opioids can be considered 1
   • NSAIDs may provide relief for some patients 2
   • Corticosteroids and strong opioids are not recommended 1

Combination Therapy

• Pregabalin + Duloxetine: Combination therapy has shown superior efficacy compared to either medication alone 7
  • This combination targets different pain mechanisms and may allow for lower doses of each medication, potentially reducing side effects 2

Non-Pharmacological Management

1. Exercise Therapy

   • Heated pool treatment with or without exercise is effective (Level IIa, Strength B) 1
   • Individually tailored exercise programs including aerobic exercise and strength training (Level IIb, Strength C) 1
   • Regular physical activity should be encouraged despite initial discomfort

2. Psychological Interventions

   • Cognitive Behavioral Therapy (CBT) may benefit some patients (Level IV, Strength D) 1, 2
   • Helps develop coping strategies and addresses negative thought patterns that amplify pain perception

3. Complementary Therapies

   • Relaxation techniques, rehabilitation, physiotherapy can be used based on individual needs (Level IIb, Strength C) 1
   • Acupuncture has demonstrated statistically significant improvement in musculoskeletal symptoms 2

Treatment Algorithm

1. Initial Assessment:

   • Comprehensive assessment of pain, function, and psychosocial context
   • Identify associated features (depression, fatigue, sleep disturbance)

2. First-Line Treatment:

   • Start with either pregabalin (75mg twice daily) OR duloxetine (30mg daily) OR amitriptyline (10-25mg at bedtime)
   • Selection based on predominant symptoms:
     • For pain with sleep disturbance: Pregabalin or amitriptyline
     • For pain with depression/anxiety: Duloxetine

3. Titration Phase:

   • Gradually increase dose over 2-4 weeks to effective dose
   • Pregabalin: Increase to 300mg/day within 1 week
   • Duloxetine: Increase to 60mg daily after 1 week
   • Amitriptyline: Increase by 10-25mg weekly to 50-75mg

4. Evaluation of Response:

   • Assess at 4-6 weeks for efficacy and tolerability
   • If inadequate response:
     • For pregabalin: Consider increasing to 450mg/day
     • For duloxetine: Consider increasing to 60mg twice daily
     • For amitriptyline: Consider increasing to maximum tolerated dose (up to 75mg)

5. Combination Therapy:

   • If monotherapy provides partial relief, consider adding a second agent with different mechanism
   • Pregabalin + duloxetine combination has strongest evidence 7

6. Concurrent Non-Pharmacological Therapy:

   • Initiate exercise program (aerobic + strength training)
   • Consider CBT, especially if psychological distress is prominent
   • Add complementary therapies based on patient preference and availability

Important Considerations

• Medication Adherence: Only about one-fifth of patients continue treatment for ≥1 year 3, emphasizing the need for close follow-up and management of side effects
• Side Effects Management:
  • Pregabalin: Monitor for somnolence, dizziness, weight gain, and peripheral edema 8
  • Duloxetine: Monitor for nausea, dry mouth, constipation, and insomnia
  • Amitriptyline: Monitor for anticholinergic effects, sedation, and cardiac effects
• Dose Adjustment: Most patients remain on the same dose throughout treatment 3, but dose adjustments based on efficacy and tolerability are recommended
• Discontinuation: Medications should be discontinued gradually to avoid withdrawal symptoms, particularly pregabalin 8

Treatment Pitfalls to Avoid

1. Overreliance on opioids: Strong opioids are not recommended for fibromyalgia and may worsen symptoms long-term 1
2. Monotherapy focus: Single medications rarely address all symptoms; combination therapy often needed 4
3. Neglecting non-pharmacological approaches: Medications alone are insufficient; exercise and psychological interventions are essential components 1
4. Inadequate dose titration: Starting with too high doses increases side effects and reduces adherence
5. Unrealistic expectations: Set realistic goals for symptom improvement rather than complete resolution

None of the currently available treatments fully address the entire spectrum of fibromyalgia symptoms, making a multidimensional approach essential for optimal management.