Review
Update on Fibromyalgia Therapy

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Abstract

Primary fibromyalgia, a poorly-understood chronic pain syndrome, is characterized by widespread musculoskeletal pain, nonrestorative sleep, fatigue, psychological distress, and specific regions of localized tenderness, all in the absence of otherwise apparent organic disease. While the etiology of fibromyalgia is unclear, accumulating data suggest that disordered central pain processing likely plays a role in the pathogenesis of symptoms. Although various pharmacological treatments have been studied and espoused for treating fibromyalgia, no single drug or group of drugs has proved to be particularly useful in treating fibromyalgia patients as a whole, and only one drug to date has earned U.S. Food and Drug Administration approval for treating the syndrome in the United States. This review critically and systematically evaluates clinical investigations of medicinal and nonmedicinal treatments for fibromyalgia dating from 1970 to 2007.

Section snippets

Tricyclic Agents

The tricyclic antidepressants were the first drugs to be intensively studied in fibromyalgia. Tricyclic antidepressants increase synaptic concentrations of both serotonin and norepinephrine in the central nervous system; increased availability of these neurotransmitters reduces pain signaling. Amitriptyline is the tricyclic antidepressant most extensively studied. Short-term studies indicate benefit in up to one third of patients13, 14, 15; if effective, benefit is usually evident within the

Nonpharmacological Interventions

A recent review by Goldenberg suggested “strong evidence for efficacy” for a variety of nonmedicinal interventions, including cardiovascular exercise, cognitive behavioral therapy, patient education in group format, and multidisciplinary therapy, as well as “moderate evidence for efficacy” for a number of other adjunctive treatments.3 In contrast to the Goldenberg review, 2 other systematic reviews came to less sanguine conclusions about the value of nonpharmacological interventions.

Complementary and Alternative Therapies for Fibromyalgia

Assessment of complementary and alternative approaches to fibromyalgia treatment is limited by a paucity of clinical trials, with the few completed trials sharing the drawbacks that afflict other fibromyalgia studies.

Meditation-based stress reduction showed benefit in one study that lacked a control group.58 Dehydroepiandrosterone provided no benefit in pain, fatigue, mood, or functional abilities.59 Melatonin has not been studied in a blinded fashion.60

Acupuncture is commonly tried by

Approach to The Patient with Fibromyalgia: Practice-Based Evidence in the Absence of Evidence-Based Practice

Despite a paucity of solid data in support of many fibromyalgia therapies, the physician caring for a fibromyalgia patient is confronted with an individual whose discomfort is significant, and whose need for melioration is unquestionable. A number of treatments have shown clinical benefit when compared with placebo (see Table), although frequently not in a majority of the patients studied. Indeed, the heterogeneity of fibromyalgia patients renders a “one-size-fits-all” approach unlikely to be

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