Little Improvement in FM Treatment Over the Last Ten Years

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The European League Against Rheumatism (EULAR) just did it's ten year update on how to manage fibromyalgia. It turns out that they hardly needed to bother. Ten years later the only "strong" recommendation they could give is for exercise. Exercise certainly is important but no studies suggest that it can resolve FM. All other treatments had "relatively modest" effects.

Ann Rheum Dis. 2016 Jul 4. pii: annrheumdis-2016-209724. doi: 10.1136/annrheumdis-2016-209724. [Epub ahead of print]EULAR revised recommendations for the management of fibromyalgia. Macfarlane GJ1, Kronisch C2, Dean LE1, Atzeni F3, Häuser W4, Fluß E1, Choy E5, Kosek E6, Amris K7, Branco J8, Dincer F9, Leino-Arjas P10, Longley K11,McCarthy GM12, Makri S13, Perrot S14, Sarzi-Puttini P15, Taylor A16, Jones GT1.

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[/fright]In fact the results were so modest that they recommended that physicians first try non-pharmacological approach to FM, no doubt relying on CBT and exercise. Other than exercise all the other treatments were judged as "weak for", as in weak for reducing pain, weak for assisting sleep, etc.

The abstract did not mention alternative FM treatments such as medical marijuana or low dose naltrexone. Oddly enough the abstract did not recommend more emphasis on developing effective treatments. Instead it recommended that studies determine which type of FM patient benefits from which therapy.

The drugs approved for FM target the central sensitization present. This report underscores how ineffective drugs aimed at stopping central sensitization have been thus far. Either drugs targeting central sensitization need to get better or other aspects of FM should be targeted. Several drugs are in clinical trials - most of which are upgrades of former drugs.

A potentially side effect free and more powerful Lyrica-based drug and a reformulation of flexeril to improve sleep are in clinical trials right now.

• A thousand person FM trial underway

In 2014 Consumer Reports, based on cost and effectiveness criteria, recommended that people with fibromyalgia try three generic drugs over the three FDA approved drugs.

• Consumer Reports Recommends Generics over FDA Approved Drugs for FM.

Ann Rheum Dis. 2016 Jul 4. pii: annrheumdis-2016-209724. doi: 10.1136/annrheumdis-2016-209724. Macfarlane GJ1, Kronisch C2, Dean LE1, Atzeni F3, Häuser W4, Fluß E1, Choy E5, Kosek E6, Amris K7, Branco J8, Dincer F9, Leino-Arjas P10, Longley K11,McCarthy GM12, Makri S13, Perrot S14, Sarzi-Puttini P15, Taylor A16, Jones GT1.

OBJECTIVE:

The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'.

METHODS:

A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations.
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RESULTS:

2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible.

Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise.

Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability).
CONCLUSIONS:

These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.