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A symptom-based approach to pharmacologic management of fibromyalgia

Nature Reviews Rheumatology volume 5, pages 191–199 (2009)Cite this article

Abstract

Fibromyalgia is a prevalent disorder that is characterized by widespread pain along with numerous other symptoms, including fatigue, poor sleep, mood disorders, and stiffness. Previous guidelines for the management of fibromyalgia recommended an approach that integrates pharmacologic and nonpharmacologic therapies selected according to the symptoms experienced by individual patients. However, they offered no recommendations for a system of patient assessment that would provide a basis for individualized treatment selection. We present a simple, rapid and easily remembered system for symptom quantitation and pharmacologic management of fibromyalgia that combines visual analogue scale symptom scores from a modified form of the disease-neutral Fibromyalgia Impact Questionnaire, with a review of medications that can be used to treat the individual symptoms. This symptom-based approach is amenable to caring for patients with fibromyalgia in a busy clinical practice.

Key Points

  • Effective treatment of fibromyalgia requires the management of all clinically relevant symptoms, using an individualized, integrative approach that combines pharmacologic and nonpharmacologic modalities

  • Pregabalin, duloxetine and milnacipran are the only FDA-approved medications for the management of fibromyalgia

  • Additional pharmacologic treatment should focus on symptoms of fatigue, insomnia (sleep quality), blues (depression and anxiety), rigidity (stiffness) and 'ow!' (pain and work interference), recalled using the mnemonic 'FIBRO'

  • The modified visual analogue scale of the Fibromyalgia Impact Questionnaire can be used to individualize pharmacologic therapy and monitor treatment response for FIBRO symptoms

  • Symptoms of fatigue, poor sleep, mood disorders, stiffness and pain can be treated with stimulants, sleep aids, antidepressants, muscle relaxants, and analgesics, respectively

  • The use of narcotics and benzodiazepines should be avoided when treating patients with fibromyalgia; steroids and NSAIDs should only be used to treat underlying inflammatory conditions if present

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Figure 1: The modified visual analogue scale of the Fibromyalgia Impact Questionnaire.
Figure 2: Proposed algorithm for the symptom-based management of fibromyalgia in clinical practice.

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Author information

Authors and Affiliations

  1. Vanderbilt University, Nashville, TN, USA

    Chad S. Boomershine

  2. University of Kentucky, Lexington, KY, USA

    Leslie J. Crofford

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Correspondence to Chad S. Boomershine.

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Competing interests

CS Boomershine has received grant/research support from Pfizer and speakers' honoraria from Eli Lilly and Company, Forest Pharmaceuticals and Pfizer, and has been a consultant for Cypress Bioscience. LJ Crofford has received grant/research support from Allergan, Boehringer Ingelheim, Pfizer and Wyeth.

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Boomershine, C., Crofford, L. A symptom-based approach to pharmacologic management of fibromyalgia. Nat Rev Rheumatol 5, 191–199 (2009). https://doi.org/10.1038/nrrheum.2009.25

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