What are the recommended treatments for fibromyalgia?

Recommended Treatments for Fibromyalgia

The optimal treatment for fibromyalgia requires a multidisciplinary approach combining non-pharmacological and pharmacological treatments, with exercise being the strongest evidence-based intervention, followed by specific medications including antidepressants and anticonvulsants. 1

Understanding Fibromyalgia

• Fibromyalgia is a complex and heterogeneous condition characterized by abnormal pain processing with widespread chronic pain, fatigue, non-refreshed sleep, cognitive impairment, and psychological distress 1
• Prevalence is approximately 2% of the general population, with higher rates in women 1, 2
• Comprehensive assessment of pain, function, and psychosocial context is essential for proper management 1

Non-Pharmacological Management

First-Line Treatments

• Aerobic and strengthening exercise has the strongest evidence (Grade A recommendation) and should be the foundation of treatment 1

  • Individually tailored exercise programs including both aerobic and strength training components 1
  • Gradually increase intensity and duration to improve adherence and effectiveness 1

• Heated pool treatment (hydrotherapy) with or without exercise is effective (Grade B recommendation) 1

• Cognitive behavioral therapy (CBT) is recommended for addressing unhelpful coping strategies, mood disorders, and pain catastrophizing 1

Additional Non-Pharmacological Options

• Multicomponent therapies combining educational/psychological approaches with exercise show benefits for reducing pain and fatigue 1

• Other physical therapies including acupuncture and rehabilitation may be beneficial depending on individual needs 1

• Meditative movement therapies such as qigong, yoga, and tai chi can be considered 1, 3

Pharmacological Management

First-Line Medications

• Antidepressants (Grade A recommendation):

  • Duloxetine (SNRI): Start at 30mg daily for 1 week, then increase to 60mg daily; maximum dose studied was 120mg/day, though no additional benefit was shown beyond 60mg/day 1, 4
  • Amitriptyline (TCA): Start at low doses (10-25mg) at bedtime and titrate based on response and tolerability 1, 3
  • Milnacipran (SNRI): Has demonstrated efficacy for pain and function 1, 5

• Anticonvulsants (Grade A recommendation):

  • Pregabalin: Start at 75mg twice daily, may increase to 300-450mg/day divided in two doses; doses above 450mg/day show no additional benefit and have more side effects 1, 6, 7
    • Common side effects include dizziness, somnolence, weight gain, and peripheral edema 7, 8

Second-Line Medications

• Tramadol (Grade A recommendation): Effective for pain management in fibromyalgia 1

  • Use cautiously due to risk of dependence and side effects 1

• Simple analgesics such as acetaminophen may be considered 1

  • NSAIDs and strong opioids are not recommended due to lack of efficacy and risk of side effects 2

Treatment Algorithm

1. Initial Approach:

   • Provide prompt diagnosis and patient education about the condition 1
   • Begin with non-pharmacological therapies, particularly exercise 1

2. If inadequate response to initial approach:

   • Add pharmacological therapy based on predominant symptoms:
     • For pain and sleep disturbance: Pregabalin (75-450mg/day) 6, 7
     • For pain and depression: Duloxetine (60mg/day) or amitriptyline (10-50mg/day) 1, 4
     • For severe pain: Consider adding tramadol 1

3. For patients with multiple symptoms or inadequate response:

   • Implement multicomponent therapy combining medication with CBT and exercise 1
   • Consider combination pharmacotherapy (e.g., pregabalin plus an antidepressant) 5, 7

Common Pitfalls and Caveats

• Medication adherence issues: Only about 20% of patients continue prescribed medications for ≥1 year; start with low doses and titrate slowly to improve tolerability 9
• Overmedication: Patients often take multiple medications (8-10 different prescriptions); carefully evaluate the need for each medication 9
• Inappropriate opioid use: Strong opioids have not demonstrated benefit in fibromyalgia and carry significant risks 1, 2
• Inadequate dose titration: More than 60% of patients remain on the same initial dose throughout treatment; appropriate dose adjustments may improve outcomes 9
• Monotherapy expectations: No single treatment addresses all fibromyalgia symptoms; a combination approach is typically needed 5
• Unrealistic expectations: Set realistic goals for symptom improvement rather than complete resolution 1