Effective Treatment for Fibromyalgia May Now Be Possible

Laurie Barclay, MD

April 18, 2014

Fibromyalgia and other "centralized" pain states are much better understood now than previously, and effective treatment is now possible, according to a clinical review published in the April 16 issue of JAMA. A conference on October 4, 2012, at the Medicine Grand Rounds, Beth Israel Deaconess Medical Center, Boston, Massachusetts, aimed to review fibromyalgia epidemiology, pathophysiology, diagnosis, and treatment.

"Fibromyalgia is present in as much as 2% to 8% of the population, is characterized by widespread pain, and is often accompanied by fatigue, memory problems, and sleep disturbances," writes Daniel J. Clauw, MD, from the University of Michigan, Ann Arbor.

The evidence base for this review was meta-analyses, contemporary evidence-based treatment guidelines, and other pertinent medical literature on fibromyalgia from 1955 to March 2014, retrieved via MEDLINE and the Cochrane Central Registry of Controlled Trials. Dr. Clauw based his treatment recommendations on the most recent guidelines from the Canadian Pain Society and graded them from 1 to 5 on the basis of the quality of underlying evidence.

Original diagnostic criteria for fibromyalgia published in 1990 required chronic widespread pain with a number of tender points, whereas newer criteria are entirely symptom-based and do not require counts of the number of tender points. A patient-completed symptom survey addresses pain locations and the presence and severity of fatigue, sleep disturbances, memory difficulties, headaches, irritable bowel, and mood problems.

Fibromyalgia can be diagnosed and treated in the primary care setting, with specialty referral needed only if the diagnosis is uncertain, if patients do not respond to treatment, or if there are significant comorbid psychiatric issues.

Pharmacological and Other Treatments Now Available

Among the many therapies currently available for managing fibromyalgia and supported by high levels of evidence are nonpharmacological modalities including education, exercise, and cognitive behavioral therapy, and pharmacologic agents such as tricyclics, serotonin norepinephrine reuptake inhibitors, and gabapentinoids.

The optimal approach to treatment is to integrate pharmacologic and nonpharmacologic therapy while involving patients as active participants. All patients should be educated about the nonprogressive nature of their condition and about the importance of playing an active role in their own care through stress reduction, sleep, and exercise.

Pharmacotherapy should be guided by symptoms accompanying pain. All patients should receive a sufficient therapeutic trial of a low-dose tricyclic drug such as cyclobenzaprine, amitriptyline, or nortriptyline. A serotonin norepinephrine reuptake inhibitor may be needed in patients with comorbid depression or fatigue, whereas comorbid anxiety or sleep issues may respond to a gabapentinoid.

Successful treatment may require concomitant use of several drug classes. Nonsteroidal anti-inflammatory drugs and acetaminophen may be useful to treat comorbid "peripheral pain generators," but opioids should be avoided.

"Fibromyalgia and other 'centralized' pain states are much better understood now than ever before," Dr. Clauw writes. "Fibromyalgia may be considered as a discrete diagnosis or as a constellation of symptoms characterized by central nervous system pain amplification with concomitant fatigue, memory problems, and sleep and mood disturbances. Effective treatment for fibromyalgia is now possible."

Dr. Clauw has performed consulting and/or served on scientific advisory boards for Pfizer, Lilly, Forest Laboratories, Johnson & Johnson, Purdue Pharma, Nuvo, Cerephex, Tonix, Iroko, and Takeda. He has received grant support from Pfizer, Forest, Merck, Nuvo, and Cerephex.

JAMA. 2014;311:1547-1555. Full text

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