This story about EULAR’s revised fibromyalgia recommendations was originally published on NationalPainReport.com. It is being republished here with permission from the editor.
Earlier this month, the European League Against Rheumatism (EULAR) released its revised recommendations for the management of fibromyalgia.
Unfortunately, there’s nothing really new about EULAR’s latest report. The group’s main conclusion is something every fibromyalgia sufferer has heard from their physician: “Based on meta-analyses, the only ‘strong for’ therapy-based recommendation in the guidelines was exercise,” read the report.
Yep, I can hear the collective sigh and eye roll from here.
To their credit, the working group, comprised of 18 members from 12 European countries, did acknowledge not much has changed since its initial recommendations made back in 2005.
“Despite the very large increase in the amount of trial data summarized in meta-analyses, there are no major changes to the approach of managing patients with fibromyalgia, although we provide new evidence in support of some additional non-pharmacological therapies,” reads the report. “In addition, all the recommendations are now firmly evidence based.”
So there we have it. Despite millions of dollars spent on research, nothing much has changed in the past 10-plus years when it comes to treating fibromyalgia. I know I’m not the only one disappointed by this admission.
The report goes on to include recommendations on patient care.
“We now recommend that non-pharmacological therapy should be first-line therapy, and then if there is a lack of effect … there should be individualized therapy according to patient need, which may include pharmacological therapy,” reads the report.
In other words, when you go to the physician, he’s supposed to recommend exercise first, then send you home to do squats and walk around the block a few times. When you come back a few weeks later still complaining about being in pain, then he can talk to you about pharmaceutical options.
EULAR made it super easy for physicians to follow their directives by including a helpful little flow chart (see page 9 of the full report). I imagine these posted on exam room walls all around the world with physicians pointing and saying, “Ut, ut, ut, you haven’t passed the fitness test yet…”
Ugh, ugh, ugh!
Well, I always try to find the positive in every situation. Every time a new set of recommendations comes out, I print them out and devour them like a raunchy novel.
You know why? Because these reports give us some of the best data available on what will help us better manage our fibromyalgia symptoms. They are a concise, easy-to-read summary of the leading research to date.
So, I thought it would be helpful to break down EULAR’s recommendations. They made it simple for me by assigning each therapy a rating of strong for, weak for, weak against and strong against.
Based on the current research, those therapies falling into the “strong for” and “weak for” are supposed to be the most effective for managing fibromyalgia. The keywords there are “supposed to be.”
“Strong for” recommendation
Out of all of the therapies evaluated, exercise was the only one to receive a “strong for” recommendation. The working group considered 20 reviews, which included more than 30 trials involving almost 2,500 patients. Despite a glut of studies, they were not able to reach a conclusion on if a certain type of exercise was more effective than another. Both land and water exercise seemed to improve symptoms.
“We were unanimous in providing a ‘strong for’ recommendation for the use of exercise, particularly given its effect on pain, physical function and well-being, availability, relatively low cost and lack of safety concerns,” read the report.
Yep, how many times have we heard that? There’s just one problem: Very few of us are actually well enough to exercise. It’s really a catch 22. They tell us we’ll get better if we exercise, but we can’t exercise until we feel better.
“Weak for” recommendations
- Amitriptyline (aka Elavil) – This older tricyclic antidepressant showed mixed results in improving pain, sleep and fatigue.
- Acupuncture – Studies found traditional and electric acupuncture were both effective at reducing fibromyalgia pain.
- Cognitive behavioral therapy (CBT) – Overall, studies have found CBT to be effective at reducing pain and disability.
- Cyclobenzaprine (aka Flexeril) – This commonly prescribed muscle relaxer is known to improve sleep in fibromyalgia, but has a high rate of side effects (mostly drowsiness, dizziness and headache).
- Hydrotherapy/spa therapy – Reviews showed fibromyalgia patients who used hydrotherapy had a significant reduction in pain.
- Meditative movement (qigong, yoga, tai chi, etc.) – EULAR was unable to make recommendations on individual types of meditative movement, but there is some evidence that these forms of exercise may improve sleep and fatigue.
- Mindfulness – Mindfulness-based stress reduction was found to reduce pain. However, EULAR noted bias in some studies.
- Multicomponent therapy – There’s some evidence that combining therapies to treat fibromyalgia may be more effective than monotherapy.
- Pregabalin (aka Lyrica) – A Cochran review found patients using pregabalin were more likely to experience a 30 percent reduction in pain than those taking placebo. There were small improvements in sleep and fatigue, but no impact on disability. (EULAR said pregabalin’s older cousin, gabapentin, should be used “for research only,” presumably because there wasn’t enough data to give a recommendation.)
- Serotonin-noradrenalin reuptake inhibitors (duloxetine aka Cymbalta, milnacipran aka Savella) – Duloxetine and milnacipran were both more likely to reduce fibromyalgia pain than placebo. There was less or no benefit on sleep and fatigue, depending on the study.
- Tramadol (aka Ultram) – There’s some evidence that Tramadol, a weaker, synthetic opioid, may be effective at reducing fibromyalgia pain. (Click here to read more about research related to using opioids for fibromyalgia.)
“Weak against” recommendations
- Biofeedback – In trials, biofeedback reduced fibromyalgia pain, but EULAR cited studies were of poor quality.
- Capsaicin – There was some evidence that capsaicin gives pain relief, but there’s limited research so far.
- Hypnotherapy – There were mixed results when using hypnotherapy for fibromyalgia pain.
- Massage – Overall, massage was not found to significantly reduce pain.
- Monoamine oxidase inhibitors (pirlindole, moclobemide, etc.) – Studies showed a moderate reduction in pain, but less of an effect on sleep or fatigue.
- NSAIDs (ibuprofen, naproxen, etc.) – There was no evidence of improvement when compared to placebo. (We should print these studies out and hand them to our physicians when they tell us to take some Aleve…)
- S-Adenosyl methionine (SAM-e) – EULAR gave a “weak against” rating because there were only a few studies with a small number of patients. More studies are needed to assess toxicity and safety. (I shared my own experience with SAM-e in a recent post.)
- Selective serotonin reuptake inhibitors (Paxil, Prozac, Zoloft, Celexa, etc.) – Overall, SSRIs showed a moderate effect on pain. There was no effect on fatigue.
“Strong against” recommendations
- Chiropractic – There have been limited studies on chiropractic care for fibromyalgia, and those that exist have been of poor quality with limited data. EULAR also cited safety concerns.
- Corticosteroids (prednisone, etc.) and strong opioids (hydrocodone, fentanyl, codeine, etc.) – EULAR issued a “strong against” recommendation for both categories of drugs “on the basis of lack of evidence of efficacy and high risk of side effects/addiction reported in individual trials,” reads the report.
- Growth hormone – EULAR cited safety concerns (sleep apnea, carpal tunnel syndrome) and says studies indicate the overall improvement in fibromyalgia patients is not “statistically significant.”
- Other complementary/alternative therapies, such as guided imagery and homeopathy – There were flaws in the available studies. More research is needed to make a proper recommendation.
- Sodium oxybate (aka Xyrem or GHB, the date rape drug) – Studies found small improvements in pain, sleep and fatigue. European and U.S. drug agencies have refused to approve Xyrem for fibromyalgia due to safety concerns.
So, what do you think? Do EULAR’s recommendations make sense? Share your feedback in the comments below!