Skip to main content
. Author manuscript; available in PMC: 2016 Oct 17.
Published in final edited form as: Pain Med. 2015 Aug 14;16(9):1709–1719. doi: 10.1111/pme.12863

Table 1.

FIBROMYALGIA SYNDROME: Theoretical and Pragmatic Underpinnings of Algorithm Recommendations

Algorithm
Component		 Comments References
30% pain
reduction as
significant		 Data on 2724 subjects from 10 placebo controlled trials of
pregabalin in diabetic neuropathy, postherpetic neuralgia,
chronic low back pain, fibromyalgia, and osteoarthritis.		 Farrar JT et al.
Clinical
importance of
changes in
chronic pain
intensity
measured on an
11-point
numerical pain
rating scale.
Pain 2001; 94:
149–158
Aerobic
exercise early
in Rx		 Strong efficacy evidence in general population of patients
with fibromyalgia; not tested explicitly in older adults.		 Goldenberg DL,
Burckhardt C,
Crofford L.
Management of
fibromyalgia
syndrome.
JAMA 2004;
292 (19): 2388–
95.


Jones KD,
Liptan GL.
Exercise
interventions in
fibromyalgia:
clinical
applications
from the
evidence.
Rheum Dis Clin
North Am. 2009
May;35(2):373–
91. PMID:
19647149


Hauser W et al.
Efficacy of
different types
of aerobic
exercise in
fibromyalgia
syndrome: a
systematic
review and
meta-analysis of
randomised
controlled trials.
Arthritis
Research &
Therapy 2010;
12(3):R79.
Strong efficacy evidence of multiple exercise benefits in
older adults in general (i.e., not specifically in those with
fibromyalgia).		 Fleg JL. Aerobic
exercise in the
elderly: a key to
successful
aging.
Discovery
Medicine 2012;
13(70): 223–8.


Hindin SB &
Zelinski EM.
Extended
practice and
aerobic exercise
interventions
benefit
untrained
cognitive
outcomes in
older adults: a
meta-analysis.
J Am Geriatr
Soc 2012;
60(1): 136–41.
Cognitive
Behavioral
Therapy
(CBT)		 Strong efficacy evidence in general population of patients
with fibromyalgia.		 Goldenberg DL,
Burckhardt C,
Crofford L.
Management of
fibromyalgia
syndrome.
JAMA 2004;
292 (19): 2388–
95.
High quality evidence is lacking specifically in older adults.
Arthritis pain self-management programs that contain some
CBT elements demonstrate efficacy.		 Hadjistavropoul
os T. Self-
management of
pain in older
persons:
helping people
help
themselves.
Pain Medicine
2012; 13 Suppl
2: S67–71
Patient
education		 There is little evidence-based data on the optimal patient
education program. Experts have recommended individual
and/or group education presented by health professionals
knowledgeable about fibromyalgia. Education sessions
would cover information about symptoms, course of
fibromyalgia, comorbid conditions, potential etiologies for
fibromyalgia, role of psychosocial factors in contributing to
pain, pharmacologic and non-pharmacologic therapy, and
self-management approaches. Education could also focus
on strategies to prevent nocebos.


Suggested Patient Education materials:

UpTo Date:

Patient Information: Fibromyalgia (The Basics)

Patient Information: Fibromyalgia (Beyond the Basics)

National Institute of Arthritis and Musculoskeletal and
Skin Diseases

http://www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp 		Nocebo in
fibromyalgia:
meta-analysis of
placebo-
controlled
clinical trials and
implications for
practice.
Mitsikostas DD,
Chalarakis NG,
Mantonakis LI,
Delicha EM,
Sfikakis PP.
Eur J Neurol.
2012
May;19(5):672–
80. PMID:
21973313

Hassett AL.
Gevirtz RN.
Nonpharmacolo
gic treatment for
fibromyalgia:
patient
education,
cognitive-
behavioral
therapy,
relaxation
techniques, and
complementary
and alternative
medicine.

Rheumatic
Diseases Clinics
of North
America.
35(2):393–407,
2009

Rooks DS.
Gautam S.
Romeling M.
Cross ML.
Stratigakis D.
Evans B.
Goldenberg DL.
Iversen MD.
Katz JN. Group
exercise,
education, and
combination
self-
management in
women with
fibromyalgia: a
randomized
trial. Archives
of Internal
Medicine.
167(20):2192–
200, 2007
Sleep disorder
evaluation		 Sleep disorders are common in people with fibromyalgia
and may be a risk factor for developing this condition		 Mork PJ. Nilsen
TI. Sleep
problems and
risk of
fibromyalgia:
Longitudinal
data on an adult
female
population in
Norway.
Arthritis &
Rheumatism.
64(1):281–4,
2012


Moldofsky H.
Management of
sleep disorders
in fibromyalgia.
Rheumatic
Diseases Clinics
of North
America.
28(2):353–65,
2002
Mood disorder
evaluation		 Fibromyalgia is frequently associated with psychiatric
disorders such as anxiety and depression		 Fietta P, Fietta
P, Manganelli P.
Fibromyalgia
and psychiatric
disorders. Acta
Biomed 2007;
78: 88–95
Medications
causing
fatigue		 Chronic fatigue is a common problem in people with
fibromyalgia. Minimizing the use of medications which
cause fatigue may help alleviate symptoms of fatigue.
Some medications that can cause fatigue include
benzodiazepines, skeletal muscle relaxants, some
antidepressants, antipsychotics, and anticonvulsants.		 Zlott DA, Byrne
M.
Mechanisms by
Which
Pharmacologic
Agents May
Contribute to
Fatigue. PM R.
2010
May;2(5):451–5.
GabapentinOL Not evaluated specifically in older adults with fibromyalgia.



Recommended as first line in veterans as it is on formulary.		 Arnold L et al.
Gabapentin in
the treatment of
fibromyalgia: a
randomized,
double-blind,
placebo-
controlled,
multicenter trial.
Arthritis Rheum
2007; 56(4):
1336–44.
Duloxetine
and

Venlafaxine		 FDA approved for treatment of fibromyalgia. Duloxetine is
non-formulary in VA.


Venlafaxine is on the VA formulary, restricted to psychiatry		 Arnold LM et al.
A double-blind,
multicenter trial
comparing
duloxetine with
placebo in the
treatment of
fibromyalgia
patients with or
without major
depressive
disorder.
Arthritis Rheum
2004; 50(9):
2974–84.


Hauser, W et al.
The Role of
Antidepressants
in the
Management of
Fibromyalgia
Syndrome: A
Systematic
Review and
Meta-Analysis.
CNS Drugs.
2012;
26(4):297–307.
Milnacipran FDA approved for the treatment of fibromyalgia. Not
recommended as not available in VA, even non-formulary.		 Derry S et al.
Milnacipran for
neuropathic
pain and
fibromyalgia in
adults.
Cochrane
Database of
Systematic
Reviews. 3:
CD008244,
2012


Hauser, W et al.
The Role of
Antidepressants
in the
Management of
Fibromyalgia
Syndrome: A
Systematic
Review and
Meta-Analysis.
CNS Drugs.
2012;
26(4):297–307.
Pregabalin FDA approved for treatment of fibromyalgia. Non-formulary
in VA.		 Arnold LM et al.
A 14-week
randomized
double-blinded,
placebo-
controlled
monotherapy
trial of
pregabalin in
patients with
fibromyalgia. J
Pain 2008; 9(9):
792–805.


Pauer L et al.
An international,
randomized,
double-blind,
placebo-
controlled,
phase III trial of
pregabalin
monotherapy in
treatment of
patients with
fibromyalgia. J
Rheum 2011;
38(12): 2643–
52.


Pauer L et al.
Long-term
maintenance of
response across
multiple
fibromyalgia
symptom
domains in a
randomized
withdrawal
study of
pregabalin. Clin
J Pain 2012;
28(7): 609–14.
NortriptylineOL
and
DesipramineOL 		There is strong efficacy evidence for amitriptyline in the
treatment of fibromyalgia, but this tricyclic antidepressant
has strong anticholinergic side effects in older adults and is
not recommended (on Beers list).


Neither nortriptyline nor desipramine are on Beers list, thus
if a tricyclic antidepressant is to be initiated, these are the
preferred agents. Both are on formulary at the VA.		 Goldenberg DL,
Burckhardt C,
Crofford L.
Management of
fibromyalgia
syndrome.
JAMA 2004;
292 (19): 2388–
95.


Hauser, W et al.
The Role of
Antidepressants
in the
Management of
Fibromyalgia
Syndrome: A
Systematic
Review and
Meta-Analysis.
CNS Drugs.
2012;
26(4):297–307.


2012 Beers
Criteria–
Journal of the
American
Geriatrics
Society
Cyclobenzapri
ne is absent
from the
algorithm.		 There is strong efficacy evidence for cyclobenzaprine in the
treatment of fibromyalgia, but because of strong
anticholinergic side effects, it is on Beers list and not
recommended for older adults.		 Goldenberg DL,
Burckhardt C,
Crofford L.
Management of
fibromyalgia
syndrome.
JAMA 2004;
292 (19): 2388–
95.


2012 Beers
Criteria–
Journal of the
American
Geriatrics
Society