Concerns with fibromyalgia guidelines

As a clinician with a practice dedicated to patients with fibromyalgia and related disorders, it is heartening to read about the advances in the research and clinical care of fibromyalgia over the past 2 decades and to see that information published in a widely read journal such as CMAJ.1 I support many of the recommendations in the 2012 Canadian guidelines,2 including the need to increase the capacity of primary care physicians to make an accurate diagnosis and initiate management of fibromyalgia, referring patients to specialists only if further expertise is required. I also agree that patients should be encouraged to take an active role in their own management and to engage in multimodal treatment.3 I would like to highlight 3 concerns with the new Canadian guidelines2 and their summary in CMAJ.1

First, the article1 does not clearly state that although fibromyalgia and major depression can be comorbid, they are not the same condition and they do not respond to the same treatments. The authors show that selective serotonin reuptake inhibitors are ineffective in fibromyalgia. In contrast, these drugs are among the drugs of choice for depression.4 The effects of duloxetine on fibromyalgia appears to be independent of depression status or antidepressant effects,5 suggesting that pain and mood pathways are different.

Second, despite citing research that shows that the evidence for exercise effects in fibromyalgia is neither convincing nor sustained, the authors recommend exercise for all patients. Exercise is an important component of treatment, but it is not possible without exacerbating pain and other symptoms for some severely affected individuals. Many patients have told me that their family doctor has told them to “exercise” but has not provided any guidance as to how to do it safely or effectively. I suggest starting at a modest intensity (e.g., 65% of age-adjusted maximum heart rate) and increasing slowly by 10% per month, as tolerated and sustained.6 In my experience, forced graded exercise, irrespective of symptom exacerbation, is not effective.

Third, one of the most perplexing issues in fibromyalgia is how to reconcile the healthy appearance of many patients with their subjective disability levels. However, the absence of objective markers for a condition is not the fault of the patient and they should not be disbelieved or penalized because of it. Physicians have the responsibility to support the needs (disability and otherwise) of patients with poorly understood conditions with the same professional ethic they have for patients with better understood conditions.