From the Guidelines
Fibromyalgia management should prioritize a multimodal approach, combining non-pharmacological and pharmacological treatments, with a focus on improving health-related quality of life, as recommended by 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 multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features, fatigue, sleep disturbance, and patient preferences and comorbidities. Initial management should focus on non-pharmacological therapies, including:
- Aerobic and strengthening exercise, which has a strong recommendation for improving symptoms 1
- Cognitive behavioral therapies, which has a weak recommendation for improving symptoms, but is still considered effective 1
- Multicomponent therapies, which has a weak recommendation for improving symptoms, but is still considered effective 1 Pharmacological management may include:
- Amitriptyline (at low dose), which has a weak recommendation for improving symptoms, but is still considered effective 1
- Duloxetine or milnacipran, which has a weak recommendation for improving symptoms, but is still considered effective 1
- Pregabalin, which has a weak recommendation for improving symptoms, but is still considered effective 1 It is essential to note that the size of effect for many treatments is relatively modest, and further research is needed to address issues clarifying to whom certain interventions may best be delivered, their effect in combination, matching patients to therapies, and the organisation of healthcare systems to optimise outcome, as outlined in the EULAR revised recommendations for the management of fibromyalgia 1. The condition results from central sensitization, where the brain and spinal cord process pain signals abnormally, amplifying sensations, and while fibromyalgia isn't progressive or life-threatening, consistent management is necessary for symptom control and improved quality of life, as highlighted in the EULAR revised recommendations for the management of fibromyalgia 1. Key aspects of management include:
- Prompt diagnosis and comprehensive assessment of pain, function, and psychosocial context
- A graduated approach to management, with a focus on non-pharmacological therapies initially
- Shared decision-making with the patient, taking into account their preferences and comorbidities
- Regular review and adjustment of treatment, as needed, to optimize outcome.
From the Research
Definition and Diagnosis of Fibromyalgia
- Fibromyalgia is a chronic, centralized pain syndrome characterized by disordered processing of painful stimuli 2.
- It is diagnosed more frequently in women and occurs globally, affecting 2% of people in the United States 2.
- The Fibromyalgia Rapid Screening Tool is a helpful screening method for patients with diffuse chronic pain 2.
- The American College of Rheumatology criteria or the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy diagnostic criteria can diagnose fibromyalgia 2.
Symptoms and Comorbidities
- Patients with fibromyalgia have diffuse chronic pain, poor sleep, fatigue, cognitive dysfunction, and mood disturbances 2.
- Comorbid conditions, such as functional somatic syndromes, psychiatric diagnoses, and rheumatologic conditions may be present 2.
- Back pain is the most frequent comorbidity in fibromyalgia patients, and hypertension, headache, depression, and sleep disorder are also common 3.
Treatment Options
- A multidisciplinary approach that incorporates nonpharmacologic therapies and medications to address problematic symptoms is most effective 2.
- Patient education, exercise, and cognitive behavior therapy can improve pain and function 2.
- Duloxetine, milnacipran, pregabalin, and amitriptyline are potentially effective medications for fibromyalgia 2, 4.
- Nonsteroidal anti-inflammatory drugs and opioids have not demonstrated benefits for fibromyalgia and have significant limitations 2.
Medication Uses and Efficacy
- A prospective cohort research study found that duloxetine, pregabalin, and milnacipran significantly improved pain, quality of life, and sleep quality in fibromyalgia patients 4.
- Duloxetine was the most effective treatment, improving pain, quality of life, and sleep quality, while pregabalin was beneficial for pain and sleep management, and milnacipran was a viable option for those with predominant fatigue 4.
- A large population-based cohort study found that patients who started common drugs for fibromyalgia had multiple comorbidities and other fibromyalgia-related medication use, but continued the treatment only for a short time 3.