Jonathan Kay, MD


November 29, 2016

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Hello. I am Dr Jonathan Kay, the Timothy S. and Elaine L. Peterson Chair in Rheumatology, and professor of medicine at the University of Massachusetts Medical School. Welcome to my Medscape blog.

Fibromyalgia is a label that is a challenge for primary care physicians and other physicians alike. Patients present with generalized pain, fatigue, and the sensation of feeling unrefreshed upon awakening, and often describe migraine headaches, shooting pains in their extremities, and increased sensitivity to light touch. Often this is associated with diarrhea and constipation. These are symptoms that many individuals experience, and it is not a disease; it is a condition of life.

Primary care physicians are frustrated by their inability to provide effective treatment for this condition. The European League Against Rheumatism published recommendations for treatment of this condition in 2007.[1] In the Annals of Rheumatic Diseases in 2016, a group of 18 rheumatologists, other health professionals, and patients from 12 European countries published revised recommendations for the treatment of this condition based upon an extensive literature review and meta-analysis of the available data.[2]

The most important conclusion that came out of these revised recommendations was that, based upon very strong level 1 level of evidence, aerobic and strengthening exercises are the strongest recommendations to treat this condition. We have always advised patients to try to become more active when they report these symptoms, but now we have very strong evidence from the literature that suggests that a supervised exercise program for aerobic conditioning and strengthening is the basis for the treatment of this symptom complex. Also based upon strong level 1 evidence, other therapies, such as acupuncture, tai chi, meditation, and cognitive therapy, were recommended.

Interestingly, pharmacologic therapy, such as duloxetine, milnacipran, or tramadol for pain; or low-dose amitriptyline, pregabalin, and cyclobenzaprine for patients who have a disturbed sleep pattern, were not very strongly recommended. In fact, the evidence was rather weak.

On the basis of these recommendations, a patient who presents with the symptom complex, which is very common in primary care and rheumatology practice, should be advised to pursue a vigorous and graded supervised exercise program for aerobic conditioning and strengthening. If their sleep pattern is disturbed, attention should be paid to sleep hygiene. Finally, some pharmacologic therapy may be initiated, but certainly not narcotic analgesics or nonsteroidal anti-inflammatory drugs, which are ineffective in this condition.

Of note in these recommendations is that selective serotonin reuptake inhibitors and monoamine oxidase inhibitors were also recommended against. The European League Against Rheumatism recommendations for the treatment of fibromyalgia now put into the peer-review literature the strong recommendation for aerobic exercise and strengthening exercise, and they relatively minimize the contribution of pharmacologic therapy.

These guidelines should be most helpful to primary care physicians who will now be able to treat patients with these symptoms in the primary care setting and not require referral to rheumatologists, unless there is clear evidence of a swollen joint or other evidence of an inflammatory disorder that would warrant other therapeutic intervention.

I certainly recommend this publication to all of you and hope that you enjoy this Medscape blog. I look forward to seeing you again on Medscape. I am Dr Jonathan Kay.


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