Israeli fibromyalgia guidelines published online in November 2013 and Canadian guidelines published in May 2013 follow in the solid footsteps of the 2010 American College of Rheumatology preliminary diagnostic criteria for fibromyalgia. The Canadian and Israeli documents eschew an extensive physical examination and a tender-point count, focus on the importance of nonpharmacologic treatments and recognize fibromyalgia as neither a distinct rheumatic nor mental disorder. German guidelines cut from similar cloth were published in 2008.
"All three guidelines focus on a multimodal approach; and we emphasize the primacy of physical activity and self-management strategies that may be augmented by interventions such as cognitive-behavioral therapy. Mary-Ann Fitzcharles, MD, lead author of the Canadian guidelines (Pain Res Manag 2013;18:119-126), said after discussing the three guidelines at the American College of Rheumatology's 2013 annual meeting, "Medications do play a role in patient care, but with the acknowledgment that responses are generally modest at best."
Jacob Ablin, MD, lead author of the Israeli guidelines (2013; 152:L742-L747; www.ima.org.il/Ima/FormStorage/Type7/clinical_68_fibrom.pdf) and director of the Fibromyalgia Clinic at the Tel-Aviv Sourasky Medical Center, told meeting attendees the Israeli and German guidelines also recommend against the use of nonsteroidal anti-inflammatory drugs, systemic steroids, benzodiazepines and thyroid hormone. Additionally, all three guidelines caution about the side effects of medications, which may mimic fibromyalgia symptoms.
"Fibromyalgia is not rheumatoid arthritis," emphasized Dr. Ablin. "Until we have true DMARDs [disease-modifying antirheumatic drugs] for fibromyalgia, pharmacologic treatment is a useful adjunct, not an imperative."
Star Role for Primary Care
Another expert in the field who was not involved with development of any of these guidelines made another important point: The Canadian guidelines put primary care doctors on the front lines. The German guidelines (Ger Med Sci 2008;9:Doc14) do the same.
"I'm familiar with the Canadian guidelines and am impressed that they turn it back to the family doc and provide tools for them to do the diagnosis and treatment in most cases," said Anthony Russell, MD, professor of medicine, University of Alberta, Edmonton, Canada, in an email toPain Medicine News.
The guidelines all focus on fibromyalgia as a cluster of symptoms with pain as the primary complaint, but with other manifestations that significantly contribute to patient suffering such as sleep disorder, fatigue and mood disorder. They all give grade A recommendations to aerobic exercise, multicomponent therapy and cognitive-behavioral therapy. Amitriptyline, started at a low dose, is given a grade A by the Canadian and Israeli guidelines, and a grade C recommendation by the Germans. The serotonin-norepinephrine reuptake inhibitors duloxetine and milnacipran (Savella, Forest Laboratories) are given a grade A recommendation by the Canadians and Israelis and grades B/C by the Germans (B for patients with comorbid depressive or generalized anxiety disorder and C for people without either of these comorbidities), whereas the anticonvulsants gabapentin and pregabalin (Lyrica, Pfizer) receive grades A and C, respectively. The evidence for other therapies such as balneotherapy (spa therapy), selective serotonin reuptake inhibitors and tramadol is more equivocal.
The German guidelines give much more credence to complementary and alternative medicine than do the other two: They give grade A recommendations to meditative movement therapies such as yoga and tai chi, and relaxation training combined with exercise, and grade C recommendations to acupuncture, biofeedback and hypnosis or guided imagery. The Israelis give a grade C recommendation for tai chi. The Canadian guidelines categorize yoga and tai chi as exercise activities.
The German and Israeli guidelines also call for stepwise treatment based on disease severity. For example, they recommend that individuals with mild or moderate fibromyalgia continue aerobic exercise, with increases as patients regain strength and overall health.
"Patients and physicians alike need to know that fibromyalgia is not a disabling condition for the majority of patients and that improvement is achievable," said Dr. Fitzcharles, associate professor of medicine, Division of Rheumatology, McGill University, Montreal, Quebec. "Contrary to many people's perception that fibromyalgia always has an adverse outcome, the objective of treatment and patient goals should to be to remain in the normal swing of life as best as possible."
