Management of Fibromyalgia in Primary Care
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
Primary care clinicians are in a position to evaluate and diagnose fibromyalgia, assess its comorbidities, and tailor treatment over the long term. For this reason, referral to a specialist is not necessary for most fibromyalgia patients.1
General practitioners and family physicians should take several key steps to develop their practice’s capacity to effectively and efficiently manage patients with fibromyalgia. Physicians should:
- develop deep insight into each individual patient’s case and help him or her accept the diagnosis
- understand the pharmacotherapeutic and other treatment options available for fibromyalgia
- tailor treatments to each patient’s symptom presentation and set realistic outcome goals
- organize a treatment team of staff and consultants that communicates well to effectively manage patients over the long-term
- understand the roles of other treatment team members
- be aware of and help patients take advantage of community resources.2
Remission may be an unrealistic goal for most patients with fibromyalgia. However, medications can significantly ameliorate symptoms and increase patients’ ability to function at work, at home, and in the community. Several pharmacologic treatments are used to treat fibromyalgia (AV 1),3–5 with the SNRIs duloxetine and milnacipran and the anticonvulsant pregabalin being the only FDA-approved agents.
To tailor treatments to the individual patient, clarify which symptoms are causing the person the most trouble. Then, work with the patient to prioritize treatment targets, which will help in selecting appropriate therapies. Pain is frequently a key target because it is pervasive in patients with fibromyalgia.6 The next major concerns may be sleep disturbances (often associated with fatigue) and/or mood disorders, which, along with pain, can be envisioned in a treatment triad (AV 2).7 Use this visualization to choose effective treatment options, some of which may alleviate more than 1 symptom. However, patients with fibromyalgia may eventually need multiple medications. The most effective approach to polypharmacy is to initiate 1 medication, stabilize it, assess treatment response and adverse events over 4 to 6 weeks, and then add an additional medication to address the remaining symptoms.
Patients who recognize the chronicity of fibromyalgia and the waxing and waning nature of the disorder are more likely to accept the time required to reach an optimal treatment combination. Although patients often have insight about their symptom course, a discussion with the physician helps them better recognize symptom patterns and how they are affected by treatments.
Most patients have tried several treatments, particularly NSAIDs and opioids for pain, by the time they receive an accurate diagnosis. Both NSAIDs and opioids are ineffective for pain associated with fibromyalgia,8 so patients with this illness may be taking high doses of these medications and may have been mistakenly labeled as drug-seeking. Patients with fibromyalgia may also have been diagnosed with depression and prescribed SSRIs, but only achieved a partial response. Typically, for these patients, the SSRI should be tapered down and treatment with an SNRI should be initiated.
Medication is only one component of a complete management strategy for fibromyalgia.9–11 Patients may need to be coached into starting a moderate exercise program, which, like pharmacotherapy, should be introduced carefully over time. To encourage physical activity, clinicians can talk to patients about increasing everyday activity rather than exercising per se; for example, walking around the block once or twice and then gradually increasing the distance. Pool exercise can also be beneficial.9 And, practicing good sleep hygiene is helpful for patients with fibromyalgia, and sleep hygiene guidance should be reviewed.10
Identify psychologists, social workers, or other therapists in the community who are skilled and experienced in managing fibromyalgia patients. When provided by someone with expertise in fibromyalgia treatment, CBT (in various approaches, including online) and massage therapy are effective.11 Several CAMs, including 5-HTP,12 are also available and might be helpful for patients with fibromyalgia.
Other treatments such as acupuncture, biofeedback, or other natural remedies need more research before their use can be recommended for patients with fibromyalgia.10 Often, patients ask questions about these therapies or indicate that they want to try them. Educate patients about the proven efficacy of other treatments over these therapies and suggest that they spend their financial resources on more effective treatment options. If, however, a patient is determined to try one of these therapies, ensure that there are no potential drug-drug interactions or adverse effects and ask to be informed about the treatment and any resulting symptomatic improvement.
To measure symptomatic improvement and optimize treatment, regular and ongoing monitoring of patients with fibromyalgia is critical, and several assessment tools are available. Use scales such as the VAS or WPI to monitor pain, the PHQ-9 to monitor depression, the FIQ to evaluate functional status, and the SF-36 to check general health.9,13 The same tool should be used at each clinical visit to track changes in the target symptoms (AV 3). The tool used may need to change as the patient’s target symptoms change over time.
Primary care clinicians are in a position to greatly help patients with fibromyalgia, in terms of both diagnosis and treatment. To effectively manage patients with this condition, physicians need to understand the burden of illness, educate patients on its chronic and complex nature, tailor treatment to address each patient’s most troublesome symptoms, and help patients take advantage of community resources. Several pharmacologic and nonpharmacologic options are used to treat fibromyalgia, so be aware of what is available and what is and is not effective. Once a patient begins taking medication, regularly evaluate treatment response with a valid assessment tool.
For Clinical Use
- Tailor treatment for fibromyalgia to address each patient’s most troubling symptoms
- Be aware of and use evidence-based pharmacologic and nonpharmacologic therapies
- Systematically administer rating scales to measure symptomatic improvement, or lack thereof, to inform treatment decisions
cyclobenzaprine (Amrix, Fexeril, and others), duloxetine (Cymbalta), fluoxetine (Prozac and others), gabapentin (Neurontin, Gralise, and others), milnacipran (Savella), pregabalin (Lyrica), tramadol (Ultram, Ryzolt, and others), zolpidem (Ambien, Edluar, and others)
5-HTP = 5-hydroxy-tryptophan, CAMs = complementary and alternative medicines, CBT = cognitive-behavioral therapy, FDA = United States Food and Drug Administration, FIQ = Fibromyalgia Impact Questionnaire, NSAIDs = nonsteroidal anti-inflammatory drugs, PHQ-9 = 9-Item Patient Health Questionnaire, SF-36 = Short-Form 36-Item Health Survey, SNRIs = serotonin-norepinephrine reuptake inhibitors, SSRIs = selective serotonin reuptake inhibitors, VAS = Visual Analog Scale, WPI = Widespread Pain Index
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