Guideline sources The following summarized guidelines for the evaluation and management of fibromyalgia (FM) are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the Egyptian Consensus Group on Fibromyalgia (ECG-FM 2022), the Italian Society of Rheumatology (ISR 2021), the European League Against Rheumatism (EULAR 2017), the National Fibromyalgia Guideline Advisory Panel (NFGAP 2013), the Spanish Interdisciplinary Consensus Group on Fibromyalgia (SICG- FM 2010), and the Brazilian Society of Rheumatology (BSR 2010). 1 2 3 4 5 6 7 8 8 8 9 Definition FM is a syndrome characterized by chronic widespread pain, fatigue, and sleep disruption. 8 Epidemiology The exact cause of FM is unknown; however, central sensitization involving genetic, immunological, and hormonal factors have been implicated. 8 Disease course Clinical manifestations of FM include chronic widespread pain (diffuse, multifocal, deep, gnawing, burning, waxing and waning, and migratory), tender joints, fatigue, sleep disturbances, weight fluctuations, morning stiffness, irritable bowel disease, cognitive disturbance, depression, https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 1/9 6/29/23, 4:05 AM Fibromyalgia Pathway anxiety, headaches, heat and cold intolerance, irritable bladder syndrome, restless legs, and Raynaud's phenomenon. 8 Prognosis and risk of recurrence FM is not associated with increased mortality. 9 Calculator Diagnostic criteria for fibromyal Guidelines 1. Screening and diagnosis Diagnostic criteria: As per ECG-FM 2022 guidelines, use the 2010 ACR diagnostic criteria for FM. A Show 2 more As per ISR 2021 guidelines: Establish the clinical diagnosis of FM based on peculiar symptoms lasting at least 3 months, excluding symptoms related to other diseases. B Consider using the 2016 review of the ACR diagnostic criteria in the initial assessment to support a clinical diagnosis, recognizing that symptoms vary over time. B Recognize that physical examination should be normal except for hypersensitivity to soft tissue pressure. B Do not confirm the diagnosis of FM syndrome based on the assessment of tender points according to the 1990 ACR diagnostic criteria. B Diagnose FM syndrome as a clinical construct without any confirmatory laboratory tests. Avoid obtaining repeated evaluations after diagnosis unless guided by the onset of new symptoms or semeiotic findings. Obtain additional laboratory and radiographic tests depending on the patient's clinical evaluation suggesting another medical condition. B As per NFGAP 2013 guidelines, diagnose FM in patients with diffuse body pain persisting for at least 3 months, possibly also having symptoms of fatigue, sleep disturbance, cognitive changes, mood disorder, and other somatic symptoms to variable degrees, unexplained by other illnesses. B Show 3 more As per BSR 2010 guidelines, recognize that FM is a complex and heterogeneous health condition with a disturbance in the processing of pain associated with other secondary characteristics. B Show 2 more 2. Diagnostic investigations https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 2/9 6/29/23, 4:05 AM Fibromyalgia Pathway Physical examination: As per EULAR 2017 guidelines, obtain a comprehensive assessment of pain, function, and psychosocial context in patients with FM. B As per NFGAP 2013 guidelines: Perform a physical examination in all patients with a symptom suggesting a diagnosis of FM. Recognize that physical examination should be within normal limits except for tenderness on pressure of soft tissues (hyperalgesia or increased pain following a painful stimulus). B Perform an examination of soft tissues for generalized tenderness by manual palpation, recognizing that the specific tender point examination according to the 1990 ACR diagnostic criteria is not required to confirm a clinical diagnosis of FM. B Laboratory and imaging tests: As per ECG-FM 2022 guidelines: Limit laboratory testing to a CBC, ESR, CRP, TSH, HCV antibodies, vitamin D, and anti- tissue transglutaminase IgA antibodies, and CK to rule out conditions that can present similarly to FM, such as endocrine diseases (hypothyroidism), rheumatic conditions (early inflammatory arthritis or polymyalgia rheumatica), celiac disease, or neurological disease (myopathy or multiple sclerosis), depending upon the clinical evaluation. B Consider obtaining musculoskeletal ultrasound to rule out inflammatory arthritic conditions wherever applicable. C As per NFGAP 2013 guidelines: Obtain limited initial laboratory testing, including CBC, ESR, CRP, CK, and TSH. B Obtain additional laboratory and radiographic tests depending on the patient's clinical evaluation suggesting another medical condition. B Mental health assessment: As per ECG-FM 2022 guidelines, consider obtaining psychological evaluation in selected patients. C As per NFGAP 2013 guidelines, identify and address other comorbid conditions, including depression, to reduce healthcare costs. B As per BSR 2010 guidelines, assess the seriousness of other symptoms, including fatigue, sleep disturbances, mood disturbances, and cognition disturbances, and the impact of these on the quality of life of the patient. B As per SICG-FM 2010 guidelines, assess the levels of depression and catastrophism in patients with FM. B 3. Medical management General principles: As per ECG-FM 2022 guidelines, recognize that there is no cure for FM. Direct treat-to-target to the reduction of symptoms, healthy lifestyle practices, and maintenance of optimal function, with patient outcome goals, clearly defined at the first visit. B Show 4 more https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 3/9 6/29/23, 4:05 AM Fibromyalgia Pathway As per EULAR 2017 guidelines, provide a graduated treatment approach in patients with FM. B Show 2 more As per NFGAP 2013 guidelines, manage patients with FM in the primary care setting. Augment this care by providing access to a multidisciplinary team where feasible. A Show 5 more Antidepressants: As per ECG-FM 2022 guidelines, consider offering duloxetine or milnacipran in patients with severe pain. B As per ISR 2021 guidelines, consider offering serotonin reuptake inhibitors (fluoxetine or paroxetine), norepinephrine (duloxetine), or TCA drugs (amitriptyline) in patients with FM syndrome. B As per EULAR 2017 guidelines, consider offering low-dose amitriptyline, duloxetine, or milnacipran in patients with FM. B As per NFGAP 2013 guidelines, consider offering TCAs, SSRIs, or SNRIs for pain and other symptoms in patients with FM. B Decide on the choice of antidepressants according to available evidence for efficacy, physician knowledge, patient characteristics, and side effect profile. C Anticonvulsants: As per ISR 2021 guidelines, consider offering anticonvulsants, particularly pregabalin, for pain-modulating properties. Initiate treatment with the lowest possible dose followed by a progressive increase in dosage with attention to adverse events. B As per EULAR 2017 guidelines, consider offering pregabalin in patients with FM. B As per NFGAP 2013 guidelines, offer anticonvulsants at the lowest possible dose, followed by up-titration with attention to adverse events, in patients with FM. A Skeletal muscle relaxants: As per ISR 2021 guidelines, consider offering cyclobenzaprine in patients with FM syndrome, especially in the context of significant sleep disturbances. B As per EULAR 2017 guidelines, consider offering cyclobenzaprine in patients with FM. B Non-opioid analgesics: As per ECG-FM 2022 guidelines, reserve NSAIDs for associated conditions, such as OA. A As per ISR 2021 guidelines, consider offering acetaminophen in selected patients. C As per NFGAP 2013 guidelines: Consider offering acetaminophen as analgesic therapy in selected patients, paying close attention to safe dosing. C Administer NSAIDs, if prescribed (particularly for associated conditions, such as OA), at the lowest dose and for the shortest possible period, given potentially serious adverse events. B Opioids: As per ECG-FM 2022 guidelines, consider offering tramadol in selected patients. Do not use strong opioids. B https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 4/9 6/29/23, 4:05 AM Fibromyalgia Pathway As per ISR 2021 guidelines, reserve a therapeutic trial with weak opioids, especially tramadol, B in patients with moderate-to-severe pain not responding to other treatment modalities. B Monitor closely pharmacological action, with particular reference to drug- dependent side effects or behavioral disorders. B Discontinue opioids in the absence of symptom improvement. B As per EULAR 2017 guidelines, consider offering tramadol in patients with FM. B As per NFGAP 2013 guidelines: Reserve a trial of opioids, beginning with a weak opioid (such as tramadol), for patients with moderate-to-severe pain unresponsive to other treatment modalities. B Avoid using strong opioids, and ensure that patients continuing opioids show improved pain and function. Monitor for continued efficacy and side effects or evidence of aberrant drug behaviors. D Cannabinoids: As per ISR 2021 guidelines, consider offering cannabinoids in patients with FM syndrome, especially in the context of significant sleep disturbances. C As per NFGAP 2013 guidelines, consider offering a trial of a prescribed pharmacological cannabinoid in patients with FM, particularly in the setting of important sleep disturbance. C Cannabinoids (CEG-CCP): offer cannabinoid-based medicines as an adjunct treatment for the management of back pain, FM pain, or other chronic pain in patients with FM not achieving an adequate response with standard analgesics. B Dopamine agonists: As per BSR 2010 guidelines, offer pramipexole to reduce pain in patients with FM, B especially in the presence of sleep disturbances and restless legs syndrome. A As per SICG-FM 2010 guidelines, offer pramipexole as a treatment option in patients with group 1 (Giesecke subgrouping) FM. B Serotonin antagonists: offer tropisetron for the management of pain in patients with FM. B Sedatives: offer zoplicone and zolpidem for the management of sleep disturbances in patients with FM. B Corticosteroids: as per ECG-FM 2022 guidelines, do not use corticosteroids in patients with FM. D 4. Nonpharmacologic interventions General principles: As per ECG-FM 2022 guidelines, offer non-pharmacological therapies as initial management, based on availability, cost, and patient preferences. B As per NFGAP 2013 guidelines, offer non-pharmacological strategies with active patient participation as an integral component of the therapeutic plan in patients with FM. A Work limitations: As per NFGAP 2013 guidelines: https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 5/9 6/29/23, 4:05 AM Fibromyalgia Pathway Encourage patients to remain in the workforce and, if necessary, provide recommendations that could help maintain optimal productivity, as outcome is generally more favorable for employed patients. B Encourage patients with FM on a prolonged sick leave to participate in an appropriate rehabilitation program with focus on improving function, including return to work if possible. B As per BSR 2010 guidelines, recognize that FM does not justify work exclusion. B Exercise: As per ECG-FM 2022 guidelines, advise patients with FM to engage in an activity, either land-based or water, that is enjoyable, easy to follow, convenient, and within budget to improve adherence, as subjective muscle pain may be a barrier to optimal exercise activity. A As per ISR 2021 guidelines: Encourage patients to pursue a regular lifestyle, gradually increasing physical activity through stimuli and/or maintaining/improving function and promoting self-management by multimodal therapy. B Consider offering the following physical therapies, adapted to the patient individual performance level, in patients with FM syndrome: aerobic resistance training strengthening exercise water activity/water jogging thermal therapy (bath in thermal springs). B As per EULAR 2017 guidelines, advise practicing aerobic and strengthening exercises in patients with FM. A As per NFGAP 2013 guidelines, advise patients with FM to participate in a graduated exercise program of their choosing for global health benefits and probable effects on FM symptoms. A Psychological interventions: As per ISR 2021 guidelines: Inform patients of the negative impact that the psychological distress associated with FM syndrome can generate. B Promote psychological assessment and counseling. B Consider offering the following psychological therapies: CBT and occupational therapy, including patient education, even for a short period B hypnosis, guided imagination, or therapeutic writing. C As per EULAR 2017 guidelines, consider offering CBT in patients with FM. B As per NFGAP 2013 guidelines, offer interventions improving self-efficacy to help patients cope with symptoms of FM. A Show 3 more Multicomponent therapies: As per EULAR 2017 guidelines, consider offering multicomponent therapies in patients with FM. B https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 6/9 6/29/23, 4:05 AM Fibromyalgia Pathway As per NFGAP 2013 guidelines, consider offering multicomponent therapy to facilitate the attainment of effective coping skills and the promotion of self-management. C Alternative and complementary therapies: As per ISR 2021 guidelines, consider offering the following non-conventional therapies: meditative movement therapies, such as qigong, yoga, and Tai chi B mindfulness-based stress reduction programs B relaxation training combined with exercise B acupuncture B hydrotherapy. B As per EULAR 2017 guidelines, consider offering the following complementary therapies in patients with FM: acupuncture hydrotherapy qigong yoga tai chi mindfulness-based stress reduction. B As per NFGAP 2013 guidelines, insufficient evidence to recommend complimentary and alternative medicine therapies for the management of FM symptoms. I As per SICG-FM 2010 guidelines, do not offer experimental therapies or alternatives of any type. D 5. Patient education General counseling: As per ECG-FM 2022 guidelines, offer education and active participation with reassurance regarding "no harm" caused by physical activity, especially if the patient is passive. Encourage self-efficacy and social support to facilitate the practice of health-promoting lifestyles. Use a graded incremental activity to maintain or improve function. B As per ISR 2021 guidelines, inform patients about the recommended and non-recommended treatment measures after FM syndrome diagnosis. B Show 4 more As per NFGAP 2013 guidelines, inform patients that the outcome in many cases is favorable, even if symptoms of FM tend to increase and decrease over time. B Show 2 more 6. Follow-up and surveillance Indications for specialist referral: consider obtaining specialist consultation, including referral to a sleep specialist or psychologist, in selected cases. Reserve continued care by a specialist in patients failed management in primary care or having more complex comorbidities. C https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 7/9 6/29/23, 4:05 AM Fibromyalgia Pathway Assessment of treatment response: As per ECG-FM 2022 guidelines, recognize that FM symptoms persist and fluctuate over time, even with treatment. Consider using early treatment response to a specific medication as a treatment effect indicator. Recognize that factors such as passivity, poor internal locus of control, cognitive dysfunction, prominent mood disorder, perfectionist, meticulous and obsessive personalities, and uncontrolled underlying disease (if any) may have a negative influence on the outcome. B As per NFGAP 2013 guidelines, consider measuring outcomes by a narrative report of symptom status or patient global impression of change, without requiring more complex questionnaires. C Show 2 more Follow-up: As per NFGAP 2013 guidelines: Schedule clinical follow-up according to the judgment of the physician or healthcare team, with more frequent visits during the initial phase of management or until symptoms are stabilized. B Monitor patients for the development of new symptoms during the continued care of FM to ensure that symptoms are not due to some other medical illness. B Clinical findings Patient demographics Symptoms Female predominance Abdominal pain Anxiety Past medical history Bloating Constipation IBS Depression Migraine Difficulty sleeping Obesity Fatigue Rheumatoid arthritis Headache SLE Joint pain TMJ syndrome Limb numbness Memory impairment Numbness of soles of feet Pain Provoked by stress Stiffness Trouble concentrating Family history Genetic predispositions References https://web.pathway.md/diseases/recB8e4Lh5NhNbbfY 8/9 6/29/23, 4:05 AM Fibromyalgia Pathway 1. C Alegre de Miquel, J Garc a Campayo, M Tom s Fl rez et al. 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