From: Biology and therapy of fibromyalgia. New therapies in fibromyalgia
Step 1 |
Confirm diagnosis |
   Identify important symptom domains and their severity (e.g., pain, sleep disturbance, fatigue) and level of function |
   Evaluate for comorbid medical and psychiatric disorders (e.g., sleep apnea, osteoarthritis, depressive or anxiety disorders); may require referral to specialist |
   Assess psychosocial stressors, level of fitness, barriers to treatment |
   Provide education about fibromyalgia (individual or group) |
   Review treatment options |
Step 2 |
Recommend treatment based on the results of the individual evaluation |
   For patients with moderate to severe pain, trial with medication as a first line approach: |
With or without lifetime depression or anxiety: trial of selective serotonin and norepinephrine reuptake inhibitor (not recommended as monotherapy for patients with comorbid bipolar disorder) |
Prominent sleep disturbance or anxiety: trial of alpha 2 delta ligand |
Partial response to monotherapy with either selective serotonin and norepinephrine reuptake inhibitor or alpha 2 delta ligand: trial of combination of these agents |
Consider other medications if no response to the above approach (e.g., selective serotonin reuptake inhibitor (SSRI); tricyclic antidepressant (TCA); combination of SSRI with low dose TCA (watch for drug interaction between SSRI and TCA); combination of SSRI and alpha 2 delta ligand) |
Avoid drugs with high likelihood of abuse or dependence |
Provide any additional treatment for comorbid conditions (e.g., non-steroidal anti-inflammatory drugs for osteoarthritis, continuous positive airway pressure for sleep apnea) |
Step 3 |
Adjunctive CBT for patients with prominent psychosocial stressors, or difficulty coping or functioning |
Exercise prescribed according to fitness level (e.g., goal of 30 to 60 minutes of low-moderate intensity aerobic exercise (e.g., walking, pool exercises, stationary bike) at least 2 to 3 times a week). |
Encourage participation in supervised or group exercise. |