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Fibromyalgia Part 2: Individualized Treatment Options for A Challenging Disease

Fibromyalgia is a condition that can present significant challenges when attempting to provide treatment recommendations. Given that it has yet to be associated with an identifiable cause, it's recommended that care be aimed at dealing with the symptoms presented by the disease - and since these effects can vary from patient to patient, an individualized approach is almost always the most effective when designing a treatment program.

In guidelines published by the Canadian Rheumatology Association (CRA), a patient focused multimodal approach is recommended, this should include consideration of both pharmacological and non-pharmacological components (including non-traditional therapies), alongside potential psychological interventions1.

Interestingly, and in contrast to other medical conditions where pain is the primary symptom, those same guidelines emphasize an approach reliant on primary care physicians rather than specialists for both the identification and management of the condition. When completing this aspect of an assessment, it is encouraged to use a patient's general practitioner as the focal point of any treatment strategy. This is linked to the belief that the established relationship between these two individuals will facilitate the most effective overall management plan.

The CRA's fibromyalgia treatment recommendations also underline the concept that patients need to be engaged and involved in their care plan in order for it to be effective2. Rather than over-medicalize the individual's condition, a plan that educates the patient, establishes a sense of internal control over treatment, helps to identify psychological distress (which can be mitigated via therapy or counselling), and establishes clear goals is important for creating a baseline for success.

In the absence of a single drug treatment for fibromyalgia symptoms, the CRA recommends starting at the lowest dose of NSAID pain management options over a short term period3. The WHO analgesic step-up ladder is also cited, although the guidelines caution against the strong opioids found at the top rung (with tramadol specifically mentioned for moderate to severe pain that is unresponsive to other therapies). Keep in mind that the effects of each of these drugs can be modest in fibromyalgia patients.

Non-traditional interventions such as cannabinoids to assist with sleep-related symptoms are also discussed by the CRA, however research in support of this option remains limited. Furthermore, an assessment may also recommend that general practitioners use their familiarity with the patient when considering the use of antidepressant or anticonvulsant medication as a treatment strategy. Of course, any existing psychological conditions should also be addressed.

Finally, a treatment plan should encourage primary care physicians to develop their own follow-up schedules with each individual based on their judgment of the patient's situation. It is important to consider the patient's overall global impression of change regarding their symptoms in order to keep them engaged throughout the treatment process, and to track goals as they are reached. The presentation of any new symptoms that may come to light during a follow-up should be evaluated in the moment, rather than in comparison with past symptoms, and other potential medical causes for these symptoms should be ruled out.

  1. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome. https://rheum.ca/images/documents/2012CanadianFMGuidelines_17August2012.pdf (accessed April 9, 2018).
  2. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Research & Management 2013;18(3):119-26.
  3. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian Fibromyalgia Guidelines. http://rheum.ca/images/documents/FMGuidelines_Slidekit_August2012.pptx (accessed April 9, 2018).