Fibromyalgia Guidelines Released by EULAR

Jennifer Garcia

July 18, 2016

Updated guidelines on fibromyalgia have been published by the European League Against Rheumatism (EULAR). The guidelines provide evidence-based recommendations, including nonpharmacologic and psychological interventions, for the management of patients with fibromyalgia, and were published online July 4 in the Annals of Rheumatic Diseases.

The new recommendations represent the first update to the EULAR guidelines for fibromyalgia management in more than a decade and include evidence to support pharmacologic, nonpharmacologic, complementary, and alternative medicines/therapies.

"[These recommendations] allow EULAR to move from recommendations that are predominantly based on expert opinion to ones that are firmly based on scientific evidence from high-quality reviews and meta-analyses," write the authors.

The working group, which included 18 members from 12 European countries, reviewed data from 107 systematic reviews and/or meta-analyses. The authors found the strongest evidence for patient education and nonpharmacologic intervention (exercise) as part of initial therapy. Beyond this, the recommendations underscore the need for an individualized approach, which may include pharmacologic, psychological, and/or rehabilitative interventions, depending on the individual patient. The authors caution, however, that the "size of effect for many treatments is relatively modest," and that further research is needed to determine optimal treatment strategies and improve patient outcomes.

"These new EULAR guidelines are based on the most up-to-date information and are in line with the thinking of most clinicians working in the area of [fibromyalgia]," Leslie J. Crofford, MD, director, Division of Rheumatology & Immunology at Vanderbilt University, Nashville, Tennessee, told Medscape Medical News.

Dr Crofford noted that although overall, the treatment recommendations made by EULAR are similar to how these patients are managed in the United States, there are some differences. For example, in the United States, "[t]here is a strong cultural pressure for pharmacologic over nonpharmacologic treatments."

Dr Crofford explained that some of this pressure may come from "advertising by pharma suggesting that drugs work better than they actually do." In addition, she posited that "a lack of knowledge of how to 'prescribe' nonpharmacologic treatments," as well as a lack of availability or access to nonpharmacologic treatments in the United States (eg, a lack of insurance coverage for psychological interventions, communities without access to therapeutic pool facilities, etc), may also contribute to the bias toward pharmacologic intervention.

When evaluating the data, the working group took into account factors such as the number of trials, number of patients, outcomes assessed, and adverse events. The group then based recommendations on a 4-point scale ("strong for/weak for/weak against/strong against"), with the strength of the recommendation based on "the balance between desirable and undesirable effects (considering values and preferences), confidence in the magnitude of effects and resource use."

In addition to the new recommendations, the committee highlighted five priority questions for research, including:

  • Is monotherapy better than a multimodal approach?

  • What type of exercise is most beneficial (strength or aerobic training)?

  • Do patient characteristics predict therapeutic response?

  • Does fibromyalgia with concurrent inflammatory joint disease require a different therapeutic approach?

  • Who is best equipped to manage patients with fibromyalgia?

The authors note that focus on these research priorities will help improve patient care by addressing "issues clarifying to whom certain interventions may best be delivered," as well as helping ensure patients are managed by the right person or part of the healthcare system.

Funding for this project was provided by EULAR. One author reports personal fees from Pierre Fabre, Pfizer, Eli Lilly and Jazz pharmaceutical for advisory boards and research activities. One author reports personal fees from Pfizer, Eli Lilly and Tonix for advisory boards and speaker fees. One author reports personal fees from MSD and Grünenthal for speaker fees. One author reports personal fees from Pfizer for research activities. One author reports personal fees from Lundbeck and Orion and research funding from Eli Lilly. One author reports personal fees from Pfizer, A. Menarini, Hospiri and BMS, and has received research funding from AbbVie and Pfizer. One author reports personal fees from Abbott, Roche, Pfizer, UCB, and MSD and has received research funding from Pfizer, UCB, and Roche. Dr Crofford has disclosed no relevant financial relationships.

Ann Rheum Dis. Published online July 4, 2016. Full text

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