Fibromyalgia: Recent Advances in

Diagnosis,Classification,Pharmacotherapy
and Alternative Remedies
 Authors

• Massimo E, Maffie

International Journal of
Molecular Sciences

Department of Life Sciences and Systems

Biology, University of Turin, Italy
 Sequence
 Introduction

 Objective

 Diagnosis

 Therapy

A. Pharmacotherapy of FM
B. Alternative therapy

 Conclusions
INTRODUCTION
A disorder characterized by :

• Widespread musculoskeletal pain and tender points accompanied by

fatigue, sleep, memory and mood issues.

• Fibrofog- Sense of slowing down

• Not a well-defined underlying organic disease

• Main trigger : Sensitivity

 Heterogenous condition

 Association with specific diseases

 Common in female

 Disturbs Quality of life

 Social and economic disruption

 Third most common diagnosis.

 Prevalence range from 1.3–8%

 No specific tests for FM.

 Objective

• Diagnosis and therapy of FM

1.Pharmacological drugs
2.Bioactive natural substances and
3.Alternative therapies
 FMS recognized by :

1. Widespread pain index

2. Symptom severity score (SSS)

Diagnosis

 Dx criteria :

 First attempt for the FM classification criteria

in 1990
 American College of Rheumatology (ACR)
2010
 American College of Rheumatology (ACR)
2011 (Modified criteria)
 Diagnosis
 American College of Rheumatology (ACR) 2010
Therapy
• Pharmacotherapy :
 50% reduction in pain intensity is by 10% to 25%

 Combination drugs Vs Monotherapy

 Low doses and gradually increased

 Individualized drug therapy


 Cannabinoids in FM Therapy

• Compounds found in the cannabis plant or synthetic compounds that can

interact with the endocannabinoid system

• Modulation of pain and stress, and the management of FM may have

therapeutic potential by manipulating this system

• Endocannabinoid system
Consists of two cannabinoid receptors, the CB1 and CB2 receptors
 Cannabinoids in FM Therapy

• CB1 : Analgesic effects are associated to CB1 agonists

• Delta 9-tetrahydrocannabinol (∆9-THC /Dronabinol,

 Significant improvement of symptoms of FM in patients using cannabis

• Synthetic cannabinoid nabilone -> Effective in FM patients

Opioids in FM Therapy

 Poor clinical evidence

 Long-term use of opioids .> Side effects

 Prescribed for 10% to 60% of patients with FM

 75% of patients preferred hydrocodone plus

acetaminophen to be helpful

 Naltrexone reduced self-reported symptoms of FM

(primarily daily pain and fatigue)
Opioids in FM Therapy
• Tramadol > SNRI like properties effective in treating FM

• Recommended in refractory and more treatment-resistant

cases of FM

• VAS and FM impact questionnaire

• Side effects of tramadol

• Codeine-acetaminophen capsules > Rx of chronic pain

Opioids in FM Therapy

• Fentanyl , efficacy , overdose and death :

• Inhibitory effects on slow temporal summation of second pain

• In 2017 USA > 29,000 overdose deaths

• Caffeine may act as an Opioid Adjuvant in FM-like chronic pain

patients
Gabapentinoids in FM Therapy
 (FDA) Anticonvulsants approved

 Pregabalin > FDA approved for FM

 In combination with antidepressants, pregabalin use showed a very

good benefit to risk ratio

 The starting approved dosage for pregabalin is at 150 mg daily

 Effective dosage : dose of 300 or 600 mg/day

 Cardinal drug to be used in FMS

Serotonin–Norepinephrine Reuptake
Inhibitors in FM Therapy
 Fibromyalgia patients with Depression, Sleep problems,
Fatigue and Pain

 Cochrane review > Duloxetine and Milnacipran

 Venlafaxine > Low cost and Good tolerability

 Mirtazapine > Inc serotonin and norepinephrine >

Imrpoved sleep, fatigue and depression

 (TCAs) Amitriptyline > Most studied and a first-line

treatment for FM
Alternative Therapies in FM Therapy

 Acupuncture
• Electric Stimulation
• Vibroacoustic and Rhythmic Sensory Stimulation
• Thermal Therapies
• Hyperbaric Treatment
• Laser Therapy and Phototherapy
• Exercise and Massage
• Use of Plant Extracts and Natural Products for FM
Treatment
Alternative Therapies in FM Therapy

 Acupuncture :
 Safe treatment for patients with FM
 The mechanisms of acupuncture > Changes in serum
serotonin levels
 Electro-acupuncture (EA) more effective > Manual
Acupuncture (MA) for improving sleep, global well-being
and fatigue and in the reduction of pain and stiffness
 Low to moderate-level in improving pain and stiffness in
people with FM.
Alternative Therapies in FM Therapy

Electric Stimulation :

• Non-invasive brain stimulation

 Cognitive dysfunctioning status known as “fibrofog” plus depression

• Use of anodal transcranial direct current stimulation over the primary motor cortex

• Low-energy pulsed electromagnetic field therapy > microcirculation

• TENS plus acupuncture

Alternative Therapies in FM Therapy

Vibroacoustic and Rhythmic Sensory Stimulation :

• Combined use of music and vibration

• Thermal Therapies :

 Body warming and cryotherapy

 Balneotherapy for Rheumatic aches in FM

 Mud-bath treatment > Muscle atrophy and inflammation and improve

nutritional condition
Alternative Therapies in FM Therapy
Hyperbaric Treatment

• Hyperbaric oxygen therapy (HBOT)

• Migraine, cluster headache and FM

• Neuroplasticity

• Brain metabolism and glial function

Alternative Therapies in FM Therapy

Laser Therapy and Phototherapy

• low-level laser therapy is a therapeutic factor

• Laser photobiomodulation therapy
• Laser therapy and amitriptyline
• Laser therapy in women suffering FM
• Combination of phototherapy and exercise training
Alternative Therapies in FM Therapy
Exercise and Massage :

• Strengthening, aerobic or stretching exercise

• Stretching exercises > Physical functioning and pain

• Resistance exercises and depression

• Shoulder/hip range of motion and handgrip strength

• Aquatic training and Yoga

• Increased oxygen uptake at peak cardiopulmonary exercise test in

Alternative Therapies in FM

Use of Plant Extracts and Natural Products for FM Treatment

 Antinociceptive properties : Papaver somniferum

 Cannabis sativa. : Cannabis, ∆9-THC

 Terpinoids : Trans-β-caryophyllene (BCP, 26) Piper nigrum

 Flavonoids

 Crocus sativus (saffron) extract or 30 mg duloxetine

Conclusions :

 Need for gold standard / supportive laboratory

finding
 A multidisciplinary therapeutic approach
 Patient education
 Combination of pharmacologic and alternative
therapy
 QUICK RECAP
 Mostly undiagnosed

 Dx of exclusion

 Widespread pain, feeling tired and sleeping problems and memory issues

 Etiology and environmental factors

 F:M ratio

• Medications ( Pregabalin, Milnacipran and duloxetine)

• Sleep hygiene, exercise and behavioral management