Fibromyalgia (FM) is a complex syndrome characterised by chronic widespread pain with a wide range of symptoms. The presence of other symptoms in FM is highly variable suggesting the condition is heterogeneous. Indeed, Giesecke et al have shown that there may be three different subgroups of patients with FM. These subgroups of patients with FM are likely to respond differently to different treatment strategies, highlighting the fact that patients should be managed according to their individual needs. This was highlighted by the EULAR recommendations for the management of FM: treatment should be tailored to the individual, addressing their particular needs and targeting their most distressing symptoms.
For most patients with FM, a multidisciplinary approach to treatment, using both pharmacological and non-pharmacological interventions is required. Any single treatment will be unlikely to be successful in treating all of the symptoms involved.
Patient education is a key aspect of management as for any chronic medical condition. Recent advances in neuroimaging have demonstrated abnormal pain processing in the brains of patients with FM. Explaining underlying pathophysiology reduces frustration and promote coping as well as self-management. Most national and international guidelines recommend graded exercise for patients with FM. FM patients are equally able to carry out exercise as healthy people, at levels tailored to each individual. Some patients find heated pool-based exercise is particularly beneficial; warm water bath can be effective for pain relief even without exercise. Cognitive behavioural therapy has been shown to improve pain and function in FM either as sole therapy or in combination with exercise.
Pharmacological managements include simple analgesia. Tramadol has been shown to reduce pain in FM. It acts centrally and inhibits norepinephrine and serotonin re-uptake whilst also being an agonist for the mu opioid receptor. Non-steroidal anti-inflammatory drugs, corticosteroids and opioids appear less effective in FM. Pregabalin, duloxetine and milnacipran have been licensed by the Food and Drugs Administration in the US for the treatment of FM although none has been licensed in Europe. Recent positive trial of sodium oxybate in FM suggests that impaired sleep may be of pathogenic importance in FM, therefore improving sleep quality in FM will be an important treatment strategy for future research.
Giesecke T, Williams DA, Harris RE, et al. Subgrouping of Fibromyalgia Patients on the Basis of Pressure-Pain Thresholds and Psychological Factors. Arthritis & Rheumatism. 2003; 48: 2916-22.
Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67:536-41.
Spaeth M, Bennett RM, Benson BA, Wang YG, Lai C, Choy EH. Sodium oxybate therapy provides multidimensional improvement in fibromyalgia: results of an international phase 3 trial. Ann Rheum Dis. 2012 [Epub ahead of print]
Disclosure of Interest E. Choy Grant/Research support from: Professor Ernest Choy has received research grantsfrom Boehringer Ingelheim, Chelsea Therapeutics, Jazz Pharmaceuticals, Pierre Fabre Medicament, Consultant for: Professor Ernest Choy has served as Consultant for Allergan, Boehringer Ingelheim, Chelsea Therapeutics, Daiichi Sankyo,Eli Lilly, Ferring Pharmacuetical, GSK, Jazz Pharmaceuticals, MedImmune, Merrimack Pharmaceutical, Pfizer, Pierre Fabre Medicament, UCB, Speakers Bureau: Professor Ernest Choy has served as member of speaker bureaus of Eli Lilly, Jazz Pharmaceuticals, Pfizer, Pierre Fabre Medicament, UCB.