Article Text

Extended report
EULAR revised recommendations for the management of fibromyalgia
  1. G J Macfarlane1,
  2. C Kronisch1,2,
  3. L E Dean1,
  4. F Atzeni3,
  5. W Häuser4,5,
  6. E Fluß1,
  7. E Choy6,
  8. E Kosek7,
  9. K Amris8,
  10. J Branco9,
  11. F Dincer10,
  12. P Leino-Arjas11,
  13. K Longley12,
  14. G M McCarthy13,
  15. S Makri14,
  16. S Perrot15,
  17. P Sarzi-Puttini16,
  18. A Taylor17,
  19. G T Jones1
  1. 1Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
  2. 2Department of Rheumatology, Cantonal Hospital, Fribourg, Switzerland
  3. 3ICRCCS Galeazzi Orthopaedic Institute, Milan, Italy
  4. 4Department of Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany
  5. 5Department of Psychosomatic Medicine, Technische Universität München, München, Germany
  6. 6Section of Rheumatology, Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
  7. 7Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Spine Centre, Stockholm, Sweden
  8. 8Department of Rheumatology, Bispebjerg and Frederiksberg, The Parker Institute, Copenhagen University Hospital, Copenhagen, Denmark
  9. 9Rheumatology Department, CEDOC-NOVA Medical School, UNL, CHLO, Hospital Egas Moniz, Lisbon, Portugal
  10. 10Hacettepe University Division of Internal Medicine, Department of Physical and Rehabilitation Medicine, Ankara, Turkey
  11. 11Finnish Institute of Occupational Health, Helsinki, Finland
  12. 12Patient Representative, Bristol, UK
  13. 13Mater Misericordiae University Hospital, Dublin, Ireland
  14. 14Patient Representative, Limassol, Cyprus
  15. 15Centre de la Douleur, Hôpital Cochin-Hôtel Dieu, Université Paris Descartes, Paris, France
  16. 16Rheumatology Unit, L. Sacco University Hospital, Milan, Italy
  17. 17Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
  1. Correspondence to Professor G J Macfarlane, Epidemiology Group, University of Aberdeen, School of Medicine, Medical Sciences and Nutrition, Polwarth Building, Foresterhill, Aberdeen, Scotland AB25 2ZD, UK; g.j.macfarlane{at}


Objective The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were ‘expert opinion’.

Methods A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.

Results 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only ‘strong for’ therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as ‘weak for’ based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).

Conclusions These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

  • Fibromyalgis/Pain Syndromes
  • Treatment
  • Multidisciplinary team-care

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  • Handling editor Tore K Kvien

  • Twitter Follow Gary Macfarlane at @UAberdeenEpi

  • Contributors GJM, FA, PS-P, EC and GTJ were applicants on the grant. EF and LED undertook the literature search and together with FA identified eligible reviews. EF, LED, FA and CK evaluated the quality of each of the eligible reviews. GTJ led the evaluation of non-pharmacological therapies and FA and CK led the evaluation of pharmacological therapies. GJM drafted the manuscript with input from GTJ, WH, EC, CK and EK. All authors (with the exception of FA and EF) participated in a 2-day project meeting, and all authors made important intellectual contributions to the manuscript.

  • Funding The project was funded by EULAR.

  • Competing interests CK undertook work in this project supported by a fellowship from the Swiss Society for Rheumatology. SP has received personal fees from Pierre Fabre, Pfizer, Eli Lilly and Jazz pharmaceutical (advisory boards and research activities). EC has received personal fees from Pfizer, Eli Lilly and Tonix (advisory boards and speaker fees). WH has received personal fees from MSD and Grünenthal (speaker fees), was head of the steering committee of the German guidelines on fibromyalgia and is a member of the medical board of the German Fibromyalgia Association. GJM has received personal fees from Pfizer (research activities). EK reports personal fees from Lundbeck, Orion and research funding from Eli Lilly. GMM reports personal fees from Pfizer, A Menarini, Hospiri and BMS, and has received research funding from AbbVie and Pfizer. PS-P reports personal fees from Abbott, Roche, Pfizer, UCB, MSD and has received research funding from Pfizer, UCB, Roche.

  • Provenance and peer review Not commissioned; externally peer reviewed.