Fibromyalgia: The Latest in Diagnosis and Care

Daniel J. Clauw, MD; Philip J. Mease, MD; Bret S. Stetka, MD


September 17, 2014

In This Article

The Latest in Management

Medscape: Given the most recent evidence, how do you currently approach treating FM patients?

Dr Clauw: Both drug and nondrug therapies can be very effective in treating FM, and in fact, most experts believe that the best approach is to combine the two different types of therapies because they are probably working on different aspects of the disorder.

The three classes of drugs with the best evidence are tricyclics (TCAs—cyclobenzaprine, amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs— duloxetine and milnacipran), and gabapentinoids (gabapentin and pregabalin). Only about a third of individuals will have a meaningful improvement with any of these classes of drugs, probably because FM can be due to abnormalities in many different neurotransmitter systems that are known to regulate pain perception, sleep, mood, and alertness.

Second-tier drug classes include higher doses of older SSRIs (sertraline, paroxetine, and fluoxetine become more noradrenergic at higher doses whereas this is not the case with citalopram or escitalopram), low-dose naltrexone, cannabinoids, and gamma hydroxybutyrate. In general, with both drug and nondrug therapies, a "start low, go slow" approach is best to avoid side effects. To improve tolerability, taking TCAs several hours before bedtime can be helpful, as can taking SNRIs with food to reduce the common side effect of initial nausea (which, as patients should be counseled, typically resolves). Similarly, the gabapentinoids are often better tolerated if they are given primarily or exclusively at bedtime.

Dr Mease: I would agree that creative combinations of approaches, using both medication and nonmedication approaches, as mentioned by Dr Clauw, are optimal for treating the symptoms of FM. Keep in mind that we are aiming to improve a number of different symptoms, including pain, fatigue, sleep disturbance, and impaired cognition, to name a few, so it is likely that no single approach will address all of these symptom domains or do so fully. Thus, we need to combine medicinal and nonmedicinal approaches.

For example, one approach may help pain but not fatigue, and another may be the opposite, so it is optimal to combine the two. Also, it is important for a patient to not expect that any therapy will completely improve symptoms. Having unrealistic expectations for breadth and depth of symptom control can lead to disappointment and frustration as well as excessive doctor- and treatment-shopping. I usually take a little time to explain, in lay terms, our current understanding of the pathophysiology of FM and then bridge to how these treatments affect that biology in a favorable way. This also allows me to explain how some drugs, such as narcotic pain medicines, may unfavorably influence the pathophysiology of FM.

Dr Clauw: The nondrug treatments that have the best evidence for efficacy are education, exercise, and cognitive-behavioral therapy (CBT). FibroGuide is a free CBT program for FM patients that has been shown to be effective in a clinical trial and can give patients access to CBT treatments to which they might not otherwise have access. Other treatments that can be effective include yoga, tai chi, acupuncture, and many other complementary and alternative medicine therapies.

Dr Mease: PCPs and allied health personnel such as nurse practitioners and physician assistants are in an ideal position to both identify and treat FM. They are seeing patients more often, know them in a holistic way, and have training about care of the individual in a family and psychosocial context. The optimal way to involve rheumatologists or other specialist physicians in FM care is for the purpose of ruling out other conditions that may be coexistent with or mimicking FM, such as early rheumatoid arthritis or lupus, which would benefit from treatment specific for those conditions. In addition, such specialists may have more insight about the array of available treatment options and experience with creative combinations tailored to the patient's particular symptom complex. Recommendations can be fed back to the PCP for ongoing care, with perhaps occasional review by the specialist. This model of care is going to become increasingly pertinent with healthcare reform.


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