The European League Against Rheumatism (EULAR), in newly revised recommendations, highlights exercise as the strongest evidence-based therapy to manage fibromyalgia. These guidelines favor nonpharmacologic approaches as an initial treatment, with more personalized therapies in cases of non-response that may include medications. The recommendations, based on 107 reviews scientific, are in the document, “EULAR revised recommendations for the management of fibromyalgia” published in the Annals of the Rheumatic Diseases.
A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological and nonpharmacological management of fibromyalgia. A review identified eligible publications in May 2015, and key outcomes assessed were pain, fatigue, sleep and daily functioning. The system known as Grading of Recommendations Assessment, Development and Evaluation was used for making the recommendations.
“These guidelines and our EULAR recommendations are in agreement on the principles of approach to management, the need for tailored therapy to the individual, and the first-line role of nonpharmacological therapies,” the authors wrote.
The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies at the time meant that most recommendations were “expert opinion.”
Since then, a considerable number of individual trials have examined pharmacological and non-pharmacological interventions, and systematic reviews were conducted for nearly all commonly used management strategies. The recommendations, however, do not represent a major change to the approach of managing patients with fibromyalgia, but rather provides new evidence in support for some additional non-pharmacological therapies.
Exercise was recommended strongly — “particularly given its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns,” the authors wrote. Existing evidence did not allow the review panel to differentiate between the benefits of aerobic or strengthening exercises.
Weak but positive recommendations were given meditative movement therapies like yoga, mindfulness-based stress reduction, acupuncture or hydrotherapy. Evidence exists that these therapies can help with fatigue, pain, sleep improvement, and quality of life.
Biofeedback, capsaicin, hypnotherapy, massage, and other complementary therapies are not recommended because of the lack of effectiveness found in the studies reviewed. The EULAR review panel gave a “strong against” evaluation for chiropractic care based on safety concerns.
In case of lack of effect of these therapeutic approaches, EULAR recommends personalized treatments according to patient needs.
The panel considers psychological therapies, such as Cognitive Behavioral Therapy, of help to patients with mood disorder or dysfunctional coping strategies. In the case of pharmacological therapies, the new EULAR recommendations consider that duloxetine, pregabalin, and tramadol can be helpful for patients with severe pain, as is amitriptyline at low dose, and that cyclobenzaprine or pregabalin should be considered for patients with sleep disturbance.
EULAR does not recommend several pharmacological therapies with nonsteroidal anti-inflammatory drugs (NSAIDs), monoamine oxidase inhibitors (MAOIs), selective serotonin re-uptake inhibitors (SSRIs), growth hormone, sodium oxybate, strong opioids, and corticosteroids because of lack of efficacy and high risk of side effects.
Patients with severe disability should be considered for multimodal rehabilitation programs rather than individual therapies.
According to the team, research priorities include identifying the most effective type of exercise, evaluating the effectiveness of a combined pharmacologic and non-pharmacologic approach compared with a single modality, as well as identifying predictors of response to specific treatments.
For those patients with incapacitating symptoms, multimodal therapy combining non-pharmacologic and pharmacologic approaches is recommended. In general, the likelihood of a good outcome for patients relies on early diagnosis, patient education, and behavioral changes including regular physical activity.