Treatment

It is important to educate patients with FMS and to reassure them that FMS is a common disease, that it is not psychiatric, and that there are treatments available.

Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) help relieve pain associated with fibromyalgia. A meta-analysis (18 RCTs with a variety of anti-depressants) concluded there was strong evidence of efficacy for antidepressants for relief of pain, fatigue, mood, sleep disturbance and health-related quality of life (Hauser et al., 2009). The effect size for pain reduction was large for TCAs and small for the SSRIs and SNRIs, although newer studies of SNRIs were not included. Studies of the SNRIs milnacipran (Savella) and duloxetine (Cymbalta) have show significant reductions in pain, and both have been FDA approved for the treatment of fibromyalgia. Amitriptyline doses are typically 25 to 50 mg at night, much lower than the doses used for the treatment of depression. The addition of amitripty-line to SSRIs or SNRIs showed a trend toward improvement versus medication alone, but results were not statistically significant (Goldenberg et al., 1996).

Cyclobenzaprine has a chemical structure similar to TCAs, and various dosing regimens have been studied in the treatment of fibromyalgia. A meta-analysis found that pain was significantly decreased in patients receiving cyclobenzaprine over placebo at 4 weeks, but not statistically significant at 8 or 12 weeks. Overall, patients treated with cyclobenzaprine were three times more likely to report subjective improvement, and five patients would need to be treated for one patient to experience symptom improvement (Tofferi et al., 2004).

Pregabalin (Lyrica), a second-generation anticonvulsant, was the first medication to be FDA approved for the treatment of fibromyalgia. As with gabapentin, pregabalin has effects on cellular calcium channels and may exert its analgesic effects by blocking various neurotransmitters. Multiple large studies have shown its efficacy for the treatment of pain, fatigue, and improvement in sleep (Mease et al., 2008). Gabapentin has not been FDA approved for this use but is efficacious for reducing pain in fibromyalgia (Arnold et al., 2007).

The NSAIDs and corticosteroids are usually not helpful because no evidence indicates FMS is an inflammatory disease, and NSAIDs are no better then placebo in the treatment of pain. Combination analgesic therapy with acetaminophen and tramadol was found to decrease pain significantly in these patients (Bennet et al., 2003). However, the long-term use of tramadol needs to be carefully considered, and this approach is best employed after other therapies (e.g., antidepressants) have failed.

At least two thirds of FMS patients use some type of complementary method, such as herbal supplements or acupuncture. A meta-analysis of acupuncture suggested benefit, but study quality was generally poor (Berman et al., 1999). Local anesthesia injected into tender points can sometimes relieve pain, and topical capsaicin (Zostrix) cream has helped some patients. Treatment of underlying depression is also important.

Daily exercise programs, particularly aerobic exercise, and physical therapy might also help FMS patients; it is important that exercise regimens begin at a low intensity and build up slowly. A review of controlled trials for aerobic exercise for fibromyalgia found beneficial effects in overall global function, physical function, and possibly in reduction of pain and tender points (Busch et al., 2008).

Cognitive-behavioral treatment (CBT) is promising for FMS patients, although there have been few controlled studies. There might be even more benefit if CBT is combined with physical exercise. Patients are often resistant to starting exercise programs such as walking or bicycling because they fear exacerbation of pain. CBT programs can overcome negative self-statements that prevent the initiation of exercise or limit the amount of exercise that can be done. An emphatic ongoing relationship with a caring physician is particularly important treatment for patients suffering from FMS. Although musculoskeletal rehabilitation has no effect by itself, physical therapy can help subacute low back pain and other comorbidities. Subacute aerobic exercise is also effective in decreasing symptoms but might need to begin at very low levels (Busch et al., 2004).

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