Non-pharmacological treatment is an important part of fibromyalgia treatment, but it is largely overlooked, according to Dr. Sterling G. West, a rheumatologist at the University of Colorado, who spoke at an internal medicine conference hosted by the university. Nonpharmacologic treatments, including physical exercise, psychological support, and stress management, are important yet often overlooked in the treatment of fibromyalgia. Exercise in warm water is a non-pharmacologic treatment that is highly recommended by the Arthritis Foundation. Patients should realize that exercise is important regardless of whether the pain is severe or mild, and that the pain may worsen when exercise is first started. Fibromyalgia patients are particularly sensitive to medications and their side effects, as well as to exercise. As with prescribing medications, it is important to develop an exercise program that starts at a low intensity and gradually builds up. It may be useful to start with 15 minutes of exercise per day and then increase the amount by 5 min/d every 1 week until you reach 30 minutes of exercise per day. The intensity of the workout should be gradually increased to moderate intensity, or up to 75% of the maximum heart rate. If exercising on the floor feels too painful at first, switching to warm water is a good alternative. The Arthritis Foundation has created pool exercise programs in every state in which fibromyalgia patients can participate Sleep apnea is fairly common in fibromyalgia patients, and many of them are not actually significantly overweight. Sleep apnea is also an issue that must be addressed in the comprehensive treatment of their pain. Clinicians often turn to experienced psychiatrists when first seeing a patient with fibromyalgia, and Dr. West always asks 2 questions when taking a history: How do you cope with the pain? Do you feel that the pain will get better sooner or later? “If the patient gives a negative answer to the 2nd question, that’s trouble because the patient has developed a catastrophic fear themselves, which means you need to seek help from a psychiatrist who is adept at dealing with pain.” In another case, the help of a psychiatric specialist is also crucial: fibromyalgia patients who have experienced sexual and/or somatic abuse early in life. The sickest fibromyalgia patients often have such experiences. “These patients may never have been asked questions related to early abuse experiences before. If you’re going to uncover this sore, it’s best to have a professional in this area on hand to assist.” There is strong evidence to support the use of cognitive-behavioral therapy to improve pain, fatigue, somatic functioning and mood. It is estimated that about 6 million U.S. adults suffer from fibromyalgia, which is more prevalent than gout. Clinical trial data show that medications for fibromyalgia are “marginally effective at best,” with “30% to 40% of patients experiencing 40% to 50% pain relief with medication.” And that’s just the average; in fact, medications work well for some patients and not at all for others. We can’t predict who will work and who won’t before we give a drug, but we have to start with one drug, and if it doesn’t work, we switch to another one until we find the one that works best. The medications with the strongest evidence of efficacy include duloxetine, milnacipran, and pregabalin, which have been approved by the U.S. Food and Drug Administration (FDA), as well as venlafaxine, gabapentin, cyclobenzaprine, and tricyclic antidepressants that are supra-adaptive.Dr. West suggests that if a patient can’t afford an approved medication, the supra-adaptive medications, which are backed up by a considerable amount of literature and relatively inexpensive, can be a good choice. They are supported by a considerable amount of literature and are relatively inexpensive. It was estimated that it would take 7.2 patients to be treated with duloxetine, or 8.6 patients to be treated with pregabalin, or 19 patients to be treated with milnacipran, to achieve a 30% reduction in pain. “I would choose the medication based on the patient’s chief complaint.” For example, for 1 patient suffering from pain, significant fatigue, and depressed mood, it would be appropriate to use duloxetine (Synthroid), which, rather surprisingly, is also approved for the treatment of osteoarthritis pain. If the patient complains of pain, cognitive dysfunction or “fibrofog” and fatigue, milnacipran (Savella) may be effective, starting with 12.5 mg in the morning with food, increasing by 12.5 mg/d weekly, and building up to a 50 mg bid. If pain is associated with sleep disorders, then there is often a good response to pregabalin (Lexapro), with an initial dose of 50 mg with food at bedtime, increasing by 25 mg/d weekly to more than 150 mg/d, and then one additional dose in the morning if necessary, up to a maximum of 225 mg bid. Tramadol’s efficacy as an add-on niche medication is supported by the evidence of “mild” efficacy for use in the treatment of pain and sleep disorders. “evidence for its efficacy as an add-on niche drug for patients whose pain is not effectively relieved by baseline pharmacologic therapy. The drug’s efficacy in fibromyalgia is not through its well-known mu-opioid receptor agonism, but rather through a 5-hydroxytryptamine-norepinephrine reuptake inhibition mechanism. Dr. West’s use of tramadol is to start at 25 mg/d and increase the dose weekly, gradually increasing to a maximum dose of 100 mg, 4 times/d. Rational combination regimens that can incorporate different mechanisms of action and are supported by efficacy data include, milnacipran + pregabalin, venlafaxine + gabapentin, and fluoxetine + amitriptyline/cyclobenzaprine. With the exception of pregabalin and gabapentin, almost all medications that have received recommendations for fibromyalgia treatment modulate 5-hydroxytryptamine. Therefore, patients need to be alerted to suicidal ideation and 5-hydroxytryptamine syndrome. One simple way to check for sudden 5-hydroxytryptamine syndrome is to periodically assess a patient’s deep tendon reflexes. “If a patient’s hyperreflexes suddenly increase dramatically, you have to start tapering the dose of medication given to avoid increasing the risk of 5-hydroxytryptamine syndrome.” Dr. West noted, “There is a gulf between the evidence-based evidence and the actual medications used in the clinic.” This divide was highlighted by data from the REFLECTIONS study, a Lilly-funded longitudinal study that recruited 1,700 patients with fibromyalgia and 91 physicians, reported at the 2011 annual meeting of the American Pain Society. These doctors prescribed a total of 186 different drugs for the treatment of fibromyalgia. Only 1/4 of the doctors used the FDA-approved drugs. Quite commonly, opioids and NSAIDs are often used for fibromyalgia sufferers despite the fact that there is no evidence that they are effective for fibromyalgia, and experts don’t think they help.