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Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: network meta-analysis
  1. Eveline Nüesch1,2,
  2. Winfried Häuser3,4,
  3. Kathrin Bernardy5,6,
  4. Jürgen Barth1,
  5. Peter Jüni1
  1. 1Institute of Social and Preventive Medicine (ISPM), University of Bern, and CTU Bern, Bern University Hospital, Bern, Switzerland
  2. 2Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, UK
  3. 3Department of Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany
  4. 4Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, München, Germany
  5. 5Department of Internal Medicine, Complementary and Integrative Medicine, University of Duisburg-Essen, Kliniken Essen-Mitte, Essen, Germany
  6. 6Department of Pain Management, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr University Bochum, Bochum, Germany
  1. Correspondence to Dr Eveline Nüesch, Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern 3012, Switzerland; enueesch{at}


Objectives To synthesise the available evidence on pharmacological and non-pharmacological interventions recommended for fibromyalgia syndrome (FMS).

Methods Electronic databases including MEDLINE, PsycINFO, Scopus, the Cochrane Controlled Trials Registry and the Cochrane Library were searched for randomised controlled trials comparing any therapeutic approach as recommended in FMS guidelines (except complementary and alternative medicine) with control interventions in patients with FMS. Primary outcomes were pain and quality of life. Data extraction was done using standardised forms.

Results 102 trials in 14 982 patients and eight active interventions (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors (SNRIs), the gamma-amino butyric acid analogue pregabalin, aerobic exercise, balneotherapy, cognitive behavioural therapy (CBT), multicomponent therapy) were included. Most of the trials were small and hampered by methodological quality, introducing heterogeneity and inconsistency in the network. When restricted to large trials with ≥100 patients per group, heterogeneity was low and benefits for SNRIs and pregabalin compared with placebo were statistically significant, but small and not clinically relevant. For non-pharmacological interventions, only one large trial of CBT was available. In medium-sized trials with ≥50 patients per group, multicomponent therapy showed small to moderate benefits over placebo, followed by aerobic exercise and CBT.

Conclusions Benefits of pharmacological treatments in FMS are of questionable clinical relevance and evidence for benefits of non-pharmacological interventions is limited. A combination of pregabalin or SNRIs as pharmacological interventions and multicomponent therapy, aerobic exercise and CBT as non-pharmacological interventions seems most promising for the management of FMS.

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