Fibromyalgia: Drug Therapy

Therapy target

To improve health-related quality of life while weighing the benefits and risks of the therapy components.

Therapy recommendations

Therapy initiation as a non-pharmacological intervention, first and foremost aerobic exercise and strength training.
If the non-pharmacological measures do not lead to success → individualized and the needs of the patient adapted pharmacological therapies (see below):
- Psychological therapies (mainly in the form of cognitive therapies – see “Further therapy” below):
  - Pain-related depression
  - Anxiety
  - Tendency to catastrophize
  - Excessively passive or active coping
- Psychopharmacological treatment:
  - Severe depression or anxiety
- Pharmacotherapy:
  - Severe pain (duloxetine, pregabalin and tramadol (possibly in combination with paracetamol).
  - Severe sleep disturbances (low-dose amytriptyline, cyclobenzaprine and pregabalin at night).
In case of response to pharmacotherapy (see overview), a drug discontinuation trial should be considered with the patient after a therapy duration of 6 months at the latest (AWMF guideline FMS).
Should not be used:
- Nonsteroidal anti-inflammatory drugs (guideline: stronger consensus).
- Strong opioids (guideline: stronger consensus).
In cases of severe functional impairment and frequent absence from work, multimodal rehab is recommended.

Note: For patients with fibromyalgia, a psychiatric diagnosis is required to identify and treat the presence of psychiatric comorbidities such as anxiety disorder, post-traumatic stress disorder (PTSD), and/or depressive disorder.

Active ingredients (main indication)

Active ingredient group	Active ingredients
First choice
Anticonvulsant	Pregalabine
Selective serotonin reuptake inhibitor	Fluoxetine
Selective serotonin reuptake inhibitor	Paroxetine
Serotonin/norepinephrine reuptake inhibitor	Duloxetine
Tricyclic antidepressants	Amitriptyline

Most agents in this indication are in off-label use (use outside the indications or group of people for which the drugs are approved by drug authorities)
Use only for a limited time, consider long-term administration in individual cases.

Supplements (dietary supplements; vital substances)

Suitable dietary supplements should contain the following vital substances:

Vitamins (vitamin D (calciferols))
Minerals (magnesium)
Other vital substances (coenzyme Q10 (CoQ10))