What is Fibromyalgia?
Fibromyalgia is a chronic disease with a complex clinical presentation. This disorder can be extremely debilitating and also interfere with normal daily activities. There is no known cure and the treatment of fibromyalgia focuses mainly on symptom management and improvement of general health.
The doctor can indicate an individual treatment plan, adapted to the needs of the individual patient suffering from fibromyalgia. Conventional medicine is based on pharmacological treatments to manage symptoms such as pain, asthenia, sleep disorders and to correct the underlying changes in the disease (in particular the serotonin deficiency). Non-pharmacological treatments, such as patient education, aerobic exercise and cognitive-behavioral therapy, can help in functional improvements and are extremely effective in modifying the neurovegetative hyperactivity present in fibromyalgia.
Recent studies have shown that it is possible to obtain a better therapeutic result by combining different multidisciplinary approaches. Indeed, integrated treatment plans have shown some effectiveness in alleviating pain and other symptoms related to fibromyalgia.
drugs
We can distinguish different classes of drugs used for the treatment of fibromyalgia.
In the treatment of chronic pain and the broader symptoms associated with the disorder, three drugs have been approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia:
- Pregabalin (approved in June 2007);
- Duloxetine (approved in June 2008);
- Milnacipran (approved in January 2009, but not in Europe).
Antidepressants
In the treatment of fibromyalgia, an initial approach that has been consolidated for many years involves the use of tricyclic antidepressants (eg amitriptyline and trazodone ), either alone or in combination with a short-acting benzodiazepine. Low doses of these drugs can be administered to alleviate multiple symptoms, partially reducing pain and sleep and mood disorders. Generally these drugs are associated with muscle relaxants. Furthermore, it is important to remember that serotonin, in addition to being involved in one of the "central" mechanisms of the disease, is also implicated in the genesis of some forms of depression, for which most drugs acting on serotonin are classified as antidepressants .
- Currently, the new selective serotonin reuptake inhibitors ( Selective Serotonin Reuptake Inhibitors, SSRIs) are preferred, such as fluoxetine or citalopram, which have been shown to be clinically effective in reducing pain and sleep disorders, as well as increasing the ability to perform daily activities.
- Serotonin and norepinephrine reuptake inhibitors (SSNRI) : they have a selective receptor-specific action on serotonin and noradrenaline transporters. These drugs, such as venlafaxine and duloxetine, can be effective in improving physical function, pain, joint stiffness and muscle tension. Serotonin and norepinephrine reuptake inhibitors are used especially where SSRIs (which act only on serotonin) prove to be ineffective.
Muscle relaxants
In the case where muscle rigidity is predominant, it may be useful to associate a central muscle relaxant, which acts on the "peripheral" manifestation of fibromyalgia, reducing muscle contraction and with it pain. Cyclobenzaprine and tizanidine are the muscle relaxants that have demonstrated the most specific action in fibromyalgia.
Analgesics
Analgesic drugs can be used to reduce inflammation, although they are often not suitable for reducing pain associated with fibromyalgia.
- Acetaminophen can relieve muscle pain and stiffness caused by fibromyalgia. However, its effectiveness is variable.
- Tramadol is a synthetic analgesic drug with central action, which can be prescribed alone or in combination with paracetamol. It has some opioid properties and has been shown to be effective in some patients with fibromyalgia.
- Your doctor may indicate, in combination with other medicines, some non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen sodium ; however the general response to therapy is partial and unsatisfactory, as confirmed by numerous studies.
antiepileptic
In fibromyalgia patients with refractory pain or hyperalgesia, the addition of a drug designed to treat epilepsy with variable results may be indicated.
These antiepileptic drugs are useful in reducing certain types of pain:
- Gabapentin : sometimes useful for treating certain symptoms, such as chronic pain.
- Pregabalin: was the first drug approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia. Pregabalin is an analogue of γ-aminobutyric acid ( GABA ), approved for the treatment of central and peripheral neurological pain, which is effective in significantly reducing pain, sleep disorders, fatigue and quality of life.
Note to pharmacological indications for fibromyalgia
- Analgesic drugs must perform an action on pain centers and must not be mere anti-inflammatories (whose effectiveness in the fibromyalgia syndrome is practically zero).
- NSAID administration is not recommended as a first-line therapy.
- At a temporal level, it may be necessary:
- up to three months to benefit from therapy with amitriptyline (antidepressant);
- up to six months to get the maximum response from duloxetine (SSNRI) and pregabalin (antiepileptic).
- Some medications can potentially cause withdrawal symptoms when therapy is stopped. For antidepressants and pregabalin, in particular, it is useful to stop treatment gradually.
Physical therapies
Physical therapies (TENS, iontophoresis, thermotherapy, etc.) are often recommended for patients with fibromyalgia; among these the TENS (Transcutaneous Electrical Nerve Stimulator, in Italian "transcutaneous electrical stimulator of the nerves") is the only one to have shown really effective results.
Cognitive behavioral therapy
The psychological factors related to the disease (the decrease in work performance, the inability to normally perform even trivial daily activities, etc.) significantly affect the severity of fibromyalgia symptoms. Some educational programs help the patient understand the disease and learn to live with it. Cognitive-behavioral therapies are treatments often related to drug therapy, which demonstrate a moderate effect in reducing the symptoms of fibromyalgia. The best effect is obtained when these measures are used in association with physical exercise.
Psychological therapies do not seem to have significant effects on pain, fatigue and sleep disorders, but help to improve mood disorders and support the patient in self-management of the disease.
