Table 3.
Comparisons with guideline recommendations.
| Proportion of users in our study | Quebec Ministry of Health “Algorithm for the Management of Fibromyalgia”2 | “Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome”8 | AHRQ—Systematic review25,32 | Evidence-based recommendations | |
|---|---|---|---|---|---|
| Medication subclass | n (%) | — | — | — | — |
| Antidepressants—Tricyclic | 14 (22.2) | Strongly recommended | Recommended | Amitriptyline has no clear effect | Cochrane systematic review42: amitriptyline recommended but diminished pain only for a minority of patients |
| Antidepressants—SNRIs | 35 (55.6) | Recommended | Recommended | Duloxetine and milnacipran are recommended (effect on pain quality of life). There is limited evidence on mid-term effects | Cochrane systematic review34: duloxetine is recommended; dose of 60 or 120 mg per day (18 studies) |
| Antidepressants—Selective serotonin reuptake inhibitors | 7 (11.1) | Recommended (sertraline, paroxetine, and fluoxetine) if intolerant to SNRI antidepressants | Recommended | — | Cochrane systematic review41: no statistical or clinal improvement in pain, fatigue, and sleep. Effective for depression in this population |
| Anticonvulsants—Calcium channel blockers (gabapentinoids) | 23 (36.5) | Recommended | Recommended starting with a low dose and then increasing (effect on pain, sleep, general condition) | Small improvement in short-term pain. Pregabalin associated with improved pain, pain response, and sleep interference (not anxiety or depression). Gabapentin has a positive effect on pain but not on quality of life | Cochrane systematic review33: pregabalin is safe and effective. Not enough evidence for gabapentin. For other anticonvulsants: not enough evidence for lacosamide and levetiracetam |
| Anticonvulsants—Sodium channel blockers | 0 (0) | — | — | — | Cochrane systematic review38: lamotrigine is not recommended Cochrane systematic review39: carbamazepine could be effective for some persons, but lack of evidence |
| Opioids associated with norepinephrine reuptake inhibitor | 15 (23.8) | Recommended for exacerbations | Recommended (pain and quality of life) for moderate to severe pain not relieved by other approaches | Lack of knowledge (one trial showing positive effect of tramadol on pain) | No Cochrane systematic review |
| Antipsychotics | 10 (15.9) | — | — | — | Cochrane systematic review37: quetiapine can be considered for a time-limited period (4–12 weeks) for patients with major depression (reduce pain, sleep problems, depression and anxiety) |
| Medical/therapeutic cannabis | 22 (34.9) | — | — | — | Cochrane systematic review36: no data available |
| Centrally acting skeletal muscle relaxants | 16 (25.4) | — | Cyclobenzaprine is recommended (effect on general improvement, sleep, fatigue, depression) | Cyclobenzaprine has no clear effect | No Cochrane systematic review |
| Synthetic cannabinoid (by prescription) | 11 (17.5) | — | May be considered, especially if sleep disorders; lack of knowledge | — | Cochrane systematic review36: two studies. Lack of knowledge to conclude |
| Acetaminophen | 46 (73.0) | Recommended for other conditions such as osteoarthritis | Recommended at low dose (hepatotoxicity); lack of knowledge | — | No Cochrane systematic review |
| NSAIDs | 34 (54.0) | Recommended for other conditions such as osteoarthritis | Recommended at low dose and for a short time, especially if osteoarthritis | Significant risk of adverse effects (serious gastrointestinal, liver dysfunction, and cardiovascular adverse effects) | Cochrane systematic review11: no efficacy of NSAIDs compared to placebo (six RCTs) |
| Various anxiolytics, sedatives, and hypnotics | 5 (7.9) | — | — | — | No Cochrane systematic review |
| Opioids | 21 (33.3) | To avoid because of the risk of misuse and overdose | Not recommended because of adverse effects. May be used in some cases according to clinical judgment; lack of knowledge | Lack of knowledge | Cochrane systematic review35: no RCT on oxycodone to reduce pain in fibromyalgia. Need for studies |
| Benzodiazepines | 17 (27.0) | To avoid (risk of dependence) | — | — | Cochrane systematic review40: no RCT on clonazepam to reduce pain in fibromyalgia |