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Fibromyalgia guidelines stress nonpharmacologic tx.


SAN DIEGO--Three sets of recent national fibromyalgia guidelines developed independently by multispe-cialty panels in Canada, Israel, and Germany all emphasize an individually tailored approach based upon the key symptoms and severity, with nonpharmacologic therapies.

The emphasis is on the necessity of self-management strategies, which include aerobic exercise, cognitive-behavioral therapy, and multicomponent exercise and psychologic therapies, according to Dr. Jacob N. Ablin. "I hope to convey the feeling that there is somewhat of a paradigm change in the recommendations regarding treatment of fibromyalgia as expressed by these three guidelines," he said at the annual meeting of the American College of Rheumatology.

"Pharmacologic therapies were less enthusiastically recommended by all three groups. Contrary to popular perception, the drugs actually achieve only relatively modest effects. And all three groups caution about the side effects of drugs, which may mimic fibromyalgia symptoms," added Dr. Ablin of the Tel Aviv Sourasky Medical Center. The three medications approved by the Food and Drug Administration for the treatment of fibromyalgia--pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella)--received only a weak grade C recommendation in the German guidelines (Schmerz 2012;26:287-90) because all three failed to achieve their primary endpoints in pivotal European clinical trials.

"While drug treatments absolutely continue to play a role in the management of fibromyalgia, the long-term safety and efficacy of nonpharmacologic treatments should be appreciated and stressed," he said.

The German and Israeli guidelines contain detailed recommendations for a variety of complementary and alternative medicine (CAM) practices, including tai chi, guided imagery, acupuncture, yoga, and spa therapy. In contrast, the Canadian guidelines (CMAJ 2013;185:E645-51) deem current evidence insufficient to support the use of CAM practices in fibromyalgia.

Dr. Mary-Ann Fitzcharles, lead author of the new Canadian guidelines, said all three guidelines, developed independently on three continents, share in common the same broad clinical concept of fibromyalgia. "We are all speaking with one voice with the same message: We accept that fibromyalgia is neither a distinct rheumatic nor mental disorder, but rather a duster of symptoms spanning a broad range of medical disciplines. We're saying that just focusing on pain is taking away from a large component of the suffering of many of these patients," according to Dr. Fitzcharles of McGill University Montreal.

The German guidelines recommend a graded approach to treatment. Patients with mild fibromyalgia are to be managed by primary care physicians, with advice given to engage in physical exercise and social activities, with no additional treatment recommended and no specialist care. In moderate fibromyalgia, the treatment plan involves aerobic exercise, time-limited psychological therapy, and referral to a specialist, with drug therapy optional. Patients with severe fibromyalgia symptoms, as well as those with moderate fibromyalgia unresponsive to the earlier-stage interventions, are best managed in a specislized day clinic or inpatient service that emphasizes psychiatric treatment of mental comorbidities.

Dr. Fitzcharles reported serving as a consultant to and/or receiving research funding from Purdue Pharma, Eli Lilly, Pfizer, and Valeant. Dr. Ablin is a consultant to Pfizer.

Caption: DR. ABLIN
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Title Annotation:GYNECOLOGY
Author:Jancin, Bruce
Publication:OB GYN News
Date:Dec 1, 2013
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