Table 5 Stepwise treatment of 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.