Exhibit 2: Core Treatment of Fibromyalgia11, 12
Confirm diagnosis
Identify important symptom domains, their severity, and level of patient function
Evaluate for comorbid medical and psychiatric disorders
Assess psychosocial stressors, level of fitness, and barriers to treatment
May require referral to a specialist for full evaluation
Provide education about fibromyalgia
Review treatment options Initiate monotherapy based on patient’s presentation and evidencebased guidelines
treating the depression that commonly accompanies chronic pain conditions. The TCAs are effective for all clinical outcomes (pain, quality of sleep, fatigue, and sense of well-being) but have safety and tolerability issues due to nonselective binding to antihistaminergic and α-adrenergic receptors. The SNRIs, duloxetine and milnacipran, are both FDA approved for treating FM and significantly improve clinical outcomes.13,14 Pregabalin, an anticonvulsant, is also FDA approved for managing FM.15 Gabapentin, another anticonvulsant approved for other types of chronic pain, has data to show it is effective but does not have FDA approval.16 None of these agents is dramatically effective. About 50 percent of patients will get a 25 percent reduction in pain relief. Only 25 percent will get a truly meaningful response of a 50 percent reduction in pain. More effective options are needed and patients need education on realistic expectations for pain reduction. For patients who predominately have exhaustion and mood symptoms, an SNRI is suggested as initial therapy. For patients with predominately pain and sleep issues, an anticonvulsant should be the initial
choice. If the initial pharmacotherapy choice does not adequately improve symptoms, it may be better to add a second medication rather than switch, however,combination therapy trials have not yet been published. Nonpharamacologic therapy is as important as medications. The nonpharmacologic strategies with strong evidence for efficacy in this condition are listed in Exhibit 4.12,17,18 Improved outcomes can be obtained by combining pharmacologic and nonpharmacologic treatments. Exercise should be recommended for all FM patients. Patient comorbidities may determine the acceptable types of exercise. Many of these patients have been sedentary for a long time and are difficult to get moving again. Obesity is also common in this patient population. Water-based exercise programs are particularly helpful because they are easiest for patients. Continued exercise is necessary to maintain positive effects on pain. Patient self-efficacy – the belief that he or she can achieve and maintain a program - is essential for sustained participation.19 Home-based ‘lifestyle physical activity’ may be
16 Journal of Managed Care Medicine | Vol. 15, No. 2 | www.namcp.org