Principles of pharmacological management for fibromyalgia

Wiffen, 2013

Drug therapy may yield only modest benefits so is best employed in conjunction with nonpharmacological management as part of a multidimensional approach. Multiple drugs may be trialled sequentially because patients with fibromyalgia commonly experience unpleasant adverse effects or have inadequate responses to treatment. Drug tolerability is often improved by starting at a low dose and slowly increasing in small increments, as described in the regimens below. Realistic goal setting is recommended, focusing on functional improvement rather than abolition of pain.

Drugs for pharmacological management of fibromyalgia lists drugs considered for the management of fibromyalgia.

Tricyclic antidepressants (TCAs), gabapentinoids and some serotonin noradrenaline reuptake inhibitors (SNRIs) have been shown to reduce pain in fibromyalgiaDerry, 2016Lunn, 2014Moore, 2019Moore, 2014; however, at the time of writing these drugs are not approved by the Australian Therapeutic Goods Administration (TGA) for this indication. Interest is growing in the use of cannabinoids to manage fibromyalgia; however, limited evidence suggests they are neither effective nor well toleratedAustralian Rheumatology Association (ARA), 2021.

Analgesia with paracetamol or a nonsteroidal anti-inflammatory drug (NSAID) is generally of little benefit. Opioid analgesics (including codeine) should not be used because they do not effectively manage pain in fibromyalgia, are associated with a significant risk of harm, and may contribute to worsening of central sensitisation over time. The exceptions are tapentadol and tramadol, which—despite having a limited role—may be prescribed by specialists with experience managing fibromyalgia. Some specialists may use a low dose of the opioid antagonist naltrexone as a treatment for fibromyalgia, because of its potential role in reducing central sensitisation.

When choosing a drug for fibromyalgia, discuss with the patient:

• the purpose and goals of pharmacological management and its place in the multidimensional approach to pain management
• any adverse drug effects and how they can be prevented and addressed.

For prescribing information, see Drug regimens for fibromyalgia.