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Treatments

As with many other medically unexplained syndromes, there is no universally accepted treatment or cure for fibromyalgia, and treatment typically consists of symptom management. Developments in the understanding of the pathophysiology of the disorder have led to improvements in treatment, which include prescription medication, behavioral intervention, exercise, and alternative and complementary medicine. Indeed, integrated treatment plans that incorporate medication, patient education, aerobic exercise and cognitive-behavioral therapy have been shown to be effective in alleviating pain and other fibromyalgia-related symptoms.  In 2005, the American Pain Society produced comprehensive guidelines for patient evaluation and management. More recently, the European League Against Rheumatism (EULAR) issued updated treatment guidelines.

A meta-analysis of 1,119 subjects found “strong evidence that multicomponent treatment has beneficial short-term effects on key symptoms of FMS.” A 2010 systematic review of 14 studies reported that CBT improves self-efficacy or coping with pain and reduces the number of physician visits at post-treatment, but has no significant effect on pain, fatigue, sleep or health related quality of life at post-treatment or follow-up. Depressed mood was also improved but this could not be distinguished from some risks of bias. A multidisciplinary approach, often including CBT is sometimes considered to be the “gold standard” of treatment for chronic pain syndromes such as fibromyalgia.

• Cognitive behavioral therapy (CBT) and related psychological/behavioral therapies are treatments which have been shown to be have a small to moderate effect in reducing symptoms of fibromyalgia in randomized controlled trials.  The greatest benefit occurs when CBT is used along with exercise.

There are three medications that have been approved by the FDA for treatment of fibromyalgia.

• Pregabalin was approved in June 2007, duloxetine was approved in June 2008, and milnacipran was approved in January 2009. Pregabalin and duloxetine have been shown to reduce pain in a substantial number of patients with fibromyalgia, but there were others who did not benefit. Placebo-controlled trials involving a total of over 2000 patients have shown milnacipran to be significantly more effective than placebo in treating both pain and the broader syndrome of fibromyalgia. The use of NSAIDs is not recommended as first line therapy. It can take up to three months to derive benefit from the antidepressant amitriptyline and up to six months to gain maximal response from duloxetine, milnacipran, and pregabalin. Some medications have the potential to cause withdrawal symptoms when stopping so gradual discontinuation may be warranted particularly for antidepressants and pregabalin.
• Antidepressants are “associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with FMS.” The goal of antidepressants in fibromyalgia should be symptom reduction and if used long term, their effects should be evaluated against side effects. The SNRIs duloxetine and milnacipran as well as the selective and reversible MAOI drug moclobemide have proven effective against fibromyalgia syndrome with the tricyclic antidepressants particularly amitriptyline and nortriptyline possibly being the most effective against pain, fatigue, and sleep problems, but tricyclic antidepressants may have more side effects due to interaction with adrenergic, cholinergic or histaminergic receptors, and sodium ion channels. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have lower side effects.
• The anti-convulsant drugs gabapentin (Neurontin) and pregabalin (Lyrica) have been tested in fibromyalgia. Gabapentin is approved for use in treatment of neuropathic pain but not in fibromyalgia. Pregabalin – originally labeled for the treatment of nerve pain suffered by diabetics – has been cleared by the US Food and Drug Administration for the treatment of fibromyalgia. A randomized controlled trial of pregabalin at a dose of 450 mg/day found that 6 patients is the number needed to treat (NNT) for one patient to have a 50% reduction in fibromyalgia-related pain. A Cochrane Database analysis of pregabalin use in chronic pain concluded that “A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events.” A meta-analysis of four trials of pregabalin in fibromyalgia found that, for patients who did respond to pregabalin, there was a reduction in their time off work of greater than 1 day per week.
• Due to the limited data supporting the use of tramadol in fibromyalgia and the absence of any data supporting the use of other weak opioids, the Association of the Scientific Medical Societies in Germany makes no recommendation against or in favor of their use, but strongly advises against using strong opioids; the European League Against Rheumatism, based mainly on expert opinion (due to the insufficient data) recommends tramadol but not strong opioids; and the Canadian Pain Society says that opioids, starting with a weak opioid like tramadol, can be tried but only for patients with otherwise intractable moderate to severe pain, and that strong opioids are discouraged, only to be used by patients who show ongoing improved pain and function. Healthcare providers must monitor patients on opioids for ongoing effectiveness, side effects and possible unwanted drug behaviours. The combination of tramadol and paracetemol has demonstrated efficacy, safety and tolerability for up to two years in the management of other pain conditions without the development of tolerance. It is as effective as codeine plus paracetamol but produces less sleepiness and constipation.
• The narcolepsy medication sodium oxybate has been studied in those with fibromyalgia, with moderate improvement in sleep, fatigue and pain symptoms. However, this medication was not approved by the FDA for the indication for use in fibromyalgia patients due to the concern for abuse.
• The muscle relaxants cyclobenzaprine and tizanidine are sometimes used off-label to treat fibromyalgia. A small clinical trial of very low doses of cyclobenzaprine taken at bedtime demonstrated improved musculoskeletal pain, fatigue, tenderness and depression in FM patients.
• Dopamine agonists (e.g. pramipexole (Mirapex) and ropinirole (ReQuip)) resulted in some improvement in a minority of patients, but numerous side effects, including the onset of impulse control disorders like compulsive gambling and shopping, have led to concern about this approach.
• Evidence exists that fibromyalgia is a neuro-immuno-endocrine disorder. Elevations in substance P, IL-6 and IL-8 as well as corticotropin-releasing hormone have been found in the cerebral spinal fluid of fibromyalgia suffering individuals. Increased numbers of mast cell numbers have been found in skin biopsies of some individuals with fibromyalgia. Quercetin, a pharmacologically active natural product which possesses anti-inflammatory in addition to mast cell inhibiting properties may be a useful treatment.[126]
• Exercise improves fitness and sleep and may reduce pain and fatigue in some people with fibromyalgia.  In particular, there is strong evidence that cardiovascular exercise is effective for some patients. Long-term aquatic-based exercise has been proven beneficial as it combines cardiovascular exercise with resistance training. However, due to the cold sensitivities of people with fibromyalgia syndrome, aquatic therapy must take place in a warm pool. Not only that, but the air temperature outside of the pool must also be heated to prevent fibromyalgia patients from getting chills and aches when out of the water. This involves a specialized pool facility, which makes this therapy more expensive and less accessible than regular swimming exercise.

 

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[list style=”arrow” el_position=”first last”]Support Links

 

• https://www.facebook.com/supportforLAF
• https://www.facebook.com/fibromyalgia.ireland
• https://www.facebook.com/groups/503462770154755/
• https://www.facebook.com/fibroawarenesspage/
• https://www.facebook.com/groups/fibrosupportgroupworldwide/

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