What are the management options for fibromyalgia (Fibromyalgia Syndrome)?

From the Guidelines

Managing fibromyalgia requires a comprehensive approach combining medication, lifestyle changes, and self-care strategies, with a focus on improving health-related quality of life and balancing benefit and risk of treatment, 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, and patient preferences and comorbidities 1. Some key considerations for managing fibromyalgia include:

• Initial management should focus on non-pharmacological therapies, such as aerobic and strengthening exercise, cognitive behavioral therapies, and multicomponent therapies 1
• Pharmacological management may include medications such as amitriptyline, duloxetine, milnacipran, tramadol, and pregabalin, which have been shown to be effective in reducing pain and improving function in patients with fibromyalgia 1
• Lifestyle changes, such as regular exercise, good sleep hygiene, and stress management techniques, can also help to reduce symptom flares and improve overall quality of life 1
• Heat therapy, such as warm showers or heating pads, can provide temporary pain relief, and pacing daily activities to avoid overexertion can help to prevent symptom flares 1 It is essential to note that the management of fibromyalgia should be individualized, taking into account the patient's specific needs, preferences, and comorbidities, and that a multidisciplinary approach, including healthcare professionals from different specialties, may be necessary to provide optimal care 1.

From the FDA Drug Label

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) The studies showed a reduction in pain by visual analog scale In addition, improvement was demonstrated based on a patient global assessment (PGIC), and on the Fibromyalgia Impact Questionnaire (FIQ) The efficacy of milnacipran hydrochloride for the management of fibromyalgia was established in two double-blind, placebo-controlled, multicenter studies in adult patients (18 to 74 years of age) A larger proportion of patients treated with milnacipran hydrochloride than with placebo experienced a simultaneous reduction in pain from baseline of at least 30% (VAS) and also rated themselves as much improved or very much improved based on the patient global assessment (PGIC)

Managing Fibromyalgia:

• Pregabalin and milnacipran are effective in managing fibromyalgia, as shown by a reduction in pain and improvement in patient global assessment and fibromyalgia impact questionnaire.
• The recommended dose of pregabalin is 300-450 mg/day, with some patients experiencing a decrease in pain as early as Week 1.
• The recommended dose of milnacipran is 100-200 mg/day, with treatment not conferring greater benefit at higher doses.
• Both studies demonstrated that patients treated with these medications experienced a significant reduction in pain and improvement in global assessment compared to placebo 2, 3.
• Key points to consider when managing fibromyalgia include:
  • Reduction in pain
  • Improvement in patient global assessment
  • Improvement in fibromyalgia impact questionnaire
  • Dosing and administration of pregabalin and milnacipran.

From the Research

Medications for Managing Fibromyalgia

• Duloxetine, milnacipran, and pregabalin are commonly used medications for managing fibromyalgia, as shown in studies 4, 5, 6.
• These medications have been found to improve pain, quality of life, and sleep quality in patients with fibromyalgia 4, 5, 6.
• A study comparing the combination of pregabalin and duloxetine found that it improved multiple clinical outcomes compared to monotherapy 5.

Combination Therapy

• Combination pharmacotherapy, such as combining pregabalin with duloxetine, may provide superior pain relief and fewer side effects compared to monotherapy 5, 7.
• However, the evidence for combination therapy is limited, and more research is needed to support its use 7.

Medication Characteristics

• Duloxetine has been found to be effective in reducing pain, improving sleep quality, and reducing depressed mood 4, 6.
• Pregabalin is beneficial for pain and sleep management, while milnacipran remains a viable option for those with predominant fatigue 4, 6.
• The risk of adverse events, such as headache and nausea, varies between medications, with duloxetine and milnacipran having a higher risk compared to pregabalin 6.

Treatment Patterns

• Patients with fibromyalgia often have multiple comorbidities and take several medications, including opioids, benzodiazepines, and muscle relaxants 8.
• The treatment duration for fibromyalgia medications is often short, with only one-fifth of patients continuing treatment for one year or more 8.