Management

At present there is no cure for FM and treatment should focus on improving symptoms and maintaining optimal function.

• there is no “gold standard” in the treatment of fibromyalgia hence a multimodal approach is best.
• a patient tailored approach with attention to individual symptoms with close monitoring and regular follow-up, particularly in the early stages of management
• patients must be encouraged to be active participants in their health care management in order to improve adherence
  • patients should be encouraged to identify specific goals regarding health status and quality of life at the initiation of treatment, with re-evaluation of goals during the follow-up

The ideal management plan should include a combination of non pharmacologic and pharmacologic treatments in a multimodal approach tailored to the individual patient (1)

Non pharmacological

• physical therapies (active)
  • exercise programs have been helpful in improving general well-being, physical function and pain and is currently recommended as the first step of a multimodal treatment strategy
  • a Cochrane systematic review of 34 studies have reported that regular aerobic exercise (at least 20 min/day, 2-3 times a week for at least 2.5 weeks) improves wellbeing, aerobic capacity, tenderness, and pain compared with no aerobic exercise.
  • strength training may also have benefits on some symptoms, but quality of evidence is lower than for aerobic exercise
• physical therapies (passive)
  • balneotherapy (heated pool or spa treatments, with or without exercise) has been shown to be effective
• acupuncture
  • immediate pain reduction following treatment has been reported but there is no evidence for long term effectiveness
  • when combined with other treatments including exercise and tricyclic antidepressants (TCAs), there was improvement in all measures of pain
• psychological therapies
  • education for patients and carers -
    • information about the disease, concerns about sinister causes for pain
    • advice on exercise etc
    • helps patients to rationalize pain in terms of lack of fitness and sleep
  • cognitive behavioural therapy (CBT) - helps patients to cope better with pain by improving pain-related behaviour, self-efficacy, and overall physical functioning, but without evidence for long-term effect when applied alone
    • there is study evidence for the effectiveness of telephone-delivered cognitive therapy in this condition (4)
  • other modalities - motivational interviewing or group sessions, meditation-based stress reduction program

Pharmacological

Choice of drug should target the most troublesome symptoms for the patient. Multiple drugs are sometimes needed. Furthermore medication should be started in low doses with gradual upward titration

• analgesics
  • in line with the WHO step-up analgesic ladder, use of paracetamol or NSAIDs may be helpful
  • should take into account patient preference, comorbidities, and adverse effects
• opioids
  • tramadol is the only drug with evidence for effectiveness in fibromyalgia
  • use of preparations containing weak opioids, such as codeine or dihydrocodeine for fibromyalgia has not been proven benificial
  • should be reserved for treatment of patients with moderate to severe pain that is unresponsive to other treatment modalities
• antidepressants
  • a meta-analysis concerning the use of antidepressant medication in fibromyalgia syndrome concluded that (3)
    • antidepressant medications are associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with FM
  • drugs recommended by guidelines include
    • amitriptyline
    • fluoxetine
    • paroxetine
    • duloxetine - not licensed for use in fibromyalgia in the UK.
    • milnacipran - is not marketed in the UK
    • moclobemide (a monamine oxidase inhibitor)
  • choice of drug is determined by the available evidence for efficacy, physician knowledge, patient characteristics, and attention to side effect profile
• anticonvulsant
  • second generation anticonvulsant pregabalin has been shown to be effective in the treatment of fibromyalgia
  • neither pregabalin nor gabapentin has a licence for use in fibromyalgia in the UK (1,2)

Reference:

• (1) Rahman A, Underwood M, Carnes D. Fibromyalgia. BMJ. 2014;348:g1224
• (2) Fitzcharles MA et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18(3):119-26.
• (3) Hauser W et al. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009 Jan 14;301(2):198-209.
• (4) McBeth J et al. Cognitive behavior therapy, exercise, or both for treating chronic widespread pain.Arch Intern Med. 2012 Jan 9;172(1):48-