Treat-to-Target Strategy Evaluated for Fibromyalgia Care

Research shows that adolescents with early-onset fibromyalgia are likely to have symptoms that persist into adulthood, but more data would help clarify long-term outcomes and potential treatment targets, says Dr. Fitzcharles.¹¹

Weighing Treatment Strategies

Standard, effective management strategies for fibromyalgia remain elusive. “Evidence indicates the best treatment intervention is the maintenance of physical activity,” says Dr. Fitzcharles. Nonpharmacologic strategies, along with selective drug treatment, have varying success.¹² “The best we can do is to keep our patients active and well conditioned. We can use medications diligently, but be cautious about side effects. Drugs for the management of fibro­myalgia symptoms have a modest effect at best, and adverse effects may outweigh the positive effects.”

In a study published in Pain in 2014, group acceptance and commitment therapy (GACT) was more effective at improving health-related quality of life than the combination drug treatment of duloxetine and pregabalin.¹³ No evidence has shown that pharmacologic interventions are effective for fatigue, a common fibromyalgia symptom, but some evidence supports the use of physical activity and cognitive-behavioral therapies.^14,15 “Ideally, if we are going to treat to target in fibromyalgia, we need treatments that work,” says Dr. Fitzcharles. A treatment algorithm with a sound evidence base and universal acceptance is necessary, along with more accurate identification of targets for treatment, she says.

An ideal treatment target should be a clinically meaningful, standard outcome measurement that is easy to perform and does not focus on only one symptom, she says. Potential targets include disease activity defined by the patient’s own narrative, or a threshold value on a composite measure such as the Fibromyalgia Impact Questionnaire or the Patient Health Questionnaire 15, according to the paper.^16,17

“I don’t think we will have a universal target in fibromyalgia. We will have to mold targets to individual patients. This is different from counting joints. It will require a different mindset for rheumatologists,” says Dr. Fitzcharles.

Well-defined patient subgroups also are needed to assess treatment effectiveness and identify who is most at risk to examine prevention strategies.

“Fibromyalgia researchers have tried to divide patients into those with primarily physical and somatic symptoms and those with primarily psychosocial symptoms. That might be a simple starting point,” says Dr. Fitzcharles. “We can look at this in two ways: the ideal world and the real world.

“In an ideal world, evidence tells us patients with fibromyalgia treated in a multidisciplinary setting do very well, but it’s expensive and not available in many places. We have to tailor our approach to the real world. We must take care not to ‘over-medicalize’ people, especially those who have an illness that’s been overlooked.”