Updated EULAR Fibromyalgia Management Recommendations

The European League Against Rheumatism (EULAR) issued updated recommendations on the management of fibromyalgia, utilizing the Grading of Recommendations Assessment, Development and Evaluation system to issue new guidelines. These recommendations were recently published in the Annals of the Rheumatic Diseases.

The original recommendations were based on evidence assessed up to 2005; most recommendations were based on expert opinion. A new multidisciplinary group from 12 countries reviewed evidence focusing on systematic reviews and meta-analyses on pharmacological/non-pharmacological management of fibromyalgia. Main outcomes analyzed included pain, fatigue, sleep, and daily functioning. 

A total of 2 979 articles were identified, of which 275 full papers and 106 reviews and/or meta-analyses were eligible. Pharmacological treatments reviewed included amitriptyline, anticonvulsants, growth hormone, monoamine oxidase inhibitors (MAOIs), non-steroidal anti-inflammatory drugs (NSAIDs), serotonin-noradrenaline reuptake inhibitors, selective serotonin reuptake inhibitors, sodium oxybate, and tramadol. 

Non-pharmacologic treatments reviewed included acupuncture, capsaicin, exercise, massage, mindfulness/mind-body therapy, among others. 

Analysis of the meta-analyses showed that exercise was the only “strong for” therapy-based recommendation. According to expert opinion, a graduated approach involving four main stages is suggested along with shared decision-making with patients. Initial management should involve patient education and non-pharmacological treatments. 

If non-responsive, additional therapies should be tailored to the specific needs of the individual and may involve psychological therapies for mood disorders and unhelpful coping methods, pharmacotherapy for severe pain or sleep disturbance, and/or a multimodal rehabilitation program for severe disability; these were evaluated as “weak for” based on meta-analyses. 

Regarding drug therapy, while other guidelines (Canada, Israel) provide strong recommendations for anticonvulsants (pregabalin, gabapentin) and SNRIs (duloxetine, milnacipran), the updated EULAR guidelines only provide a weak one. 

The updated recommendations are based on high-quality reviews and meta-analyses. Study authors call for prioritized research to determine who will benefit from specific interventions and “their effect in combination and organization of healthcare systems to optimize outcome.” 

The committee also recommended a review in 5 years to see whether treatments with relatively small current evidence have been studied in more trials, and to see whether new treatments have been developed to manage fibromyalgia.

Limitations and Disclosures

“Despite this evidence [from high-quality reviews and meta-analyses], however, the size of effect for many treatments is relatively modest”, the researchers noted. 

Reference

Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2016; Published online ahead of print July 4, 2016. doi:10.1136/annrheumdis-2016-209724

This article originally appeared on MPR