From the Guidelines
Fibromyalgia pain is best managed with a multidisciplinary approach that combines non-pharmacological and pharmacological treatments, prioritizing aerobic and strengthening exercise, cognitive behavioral therapies, and medications like amitriptyline, duloxetine, or pregabalin. According to the EULAR revised recommendations for the management of fibromyalgia 1, the optimal management of fibromyalgia requires a comprehensive assessment of pain, function, and psychosocial context. The management should aim at improving health-related quality of life, balancing benefit and risk of treatment, and often requires a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features, and patient preferences and comorbidities.
Non-Pharmacological Management
The following non-pharmacological therapies are recommended:
- Aerobic and strengthening exercise, which has a strong recommendation for 100% of patients 1
- Cognitive behavioral therapies, which has a weak recommendation for 100% of patients 1
- Multicomponent therapies, which has a weak recommendation for 93% of patients 1
- Defined physical therapies like acupuncture or hydrotherapy, which has a weak recommendation for 93% of patients 1
- Meditative movement therapies like qigong, yoga, or tai chi, and mindfulness-based stress reduction, which has a weak recommendation for 71-73% of patients 1
Pharmacological Management
The following pharmacological therapies are recommended:
- Amitriptyline at low dose, which has a weak recommendation for 100% of patients 1
- Duloxetine or milnacipran, which has a weak recommendation for 100% of patients 1
- Tramadol, which has a weak recommendation for 100% of patients 1
- Pregabalin, which has a weak recommendation for 94% of patients 1
- Cyclobenzaprine, which has a weak recommendation for 75% of patients 1
Key Considerations
When managing fibromyalgia, it is essential to consider the patient's individual needs, preferences, and comorbidities. A shared decision-making approach with the patient is crucial to develop a personalized treatment plan. Regular follow-up and monitoring of treatment response are also essential to adjust the treatment plan as needed.
From the FDA Drug Label
The efficacy of duloxetine delayed-release capsules for the management of fibromyalgia in adults was established in two randomized, double-blind, placebo-controlled, fixed-dose trials in adult patients meeting the American College of Rheumatology criteria for fibromyalgia Treatment with duloxetine delayed-release capsules 60 mg or 120 mg daily statistically significantly improved the endpoint mean pain scores from baseline and increased the proportion of patients with at least a 50% reduction in pain score from baseline The efficacy of pregabalin for management of fibromyalgia was established in one 14-week, double-blind, placebo-controlled, multicenter study (F1) and one six-month, randomized withdrawal study (F2) Studies F1 and F2 enrolled patients with a diagnosis of fibromyalgia using the American College of Rheumatology (ACR) criteria (history of widespread pain for 3 months, and pain present at 11 or more of the 18 specific tender point sites)
Fibromyalgia pain treatment options include:
- Duloxetine: 60 mg or 120 mg daily, which has been shown to statistically significantly improve endpoint mean pain scores from baseline and increase the proportion of patients with at least a 50% reduction in pain score from baseline 2
- Pregabalin: 300 mg, 450 mg, or 600 mg daily, which has been shown to reduce pain by visual analog scale and improve patient global assessment and Fibromyalgia Impact Questionnaire scores 3
From the Research
Fibromyalgia Pain Treatment Options
Fibromyalgia is a complex syndrome characterized by widespread pain, sleep disturbance, fatigue, and cognitive disturbance, among other symptoms 4. The treatment of fibromyalgia pain involves a multidisciplinary approach, including:
- Education: Patient education is a crucial component of fibromyalgia management, as it helps patients understand their condition and develop coping strategies 4, 5, 6.
- Exercise: Aerobic exercise and cognitive-behavioral therapy have been shown to be effective in alleviating fibromyalgic symptoms 4, 5, 6.
- Medications: Various medications, such as serotonin noradrenaline reuptake inhibitors (SNRI) and alpha2-delta receptor ligands, have been shown to be effective in reducing pain and other symptoms of fibromyalgia 4, 7, 8.
- Combination therapy: Combining medications, such as pregabalin and duloxetine, has been shown to improve multiple clinical outcomes compared to monotherapy 8.
Medication Options
Some commonly used medications for fibromyalgia pain treatment include:
- Amitriptyline: An antidepressant that has been used to treat fibromyalgia symptoms, although its effectiveness can vary 7.
- Duloxetine: An SNRI that has been shown to be effective in reducing pain and other symptoms of fibromyalgia 4, 7, 8.
- Gabapentin: An antiepileptic medication that has been used to treat fibromyalgia symptoms, although its effectiveness can vary 7.
- Pregabalin: An alpha2-delta receptor ligand that has been shown to be effective in reducing pain and other symptoms of fibromyalgia 4, 7, 8.
Treatment Approach
The treatment of fibromyalgia requires a holistic, comprehensive, and patient-centered approach, taking into account the individual's unique symptoms, comorbidities, and response to treatment 6. A multidisciplinary team, including healthcare professionals, therapists, and educators, can work together to develop a personalized treatment plan that addresses the physical, emotional, and social aspects of fibromyalgia.