Current and Emerging Pharmacotherapy for Fibromyalgia

Select terpenes from Cannabis sativa are antinociceptive in mouse models of post-operative pain and fibromyalgia via adenosine A2a receptors

BACKGROUND

Terpenes from Cannabis show promise for pain management. Our lab found that the terpenes geraniol, linalool, β-caryophyllene, and α-humulene relieve chemotherapy-induced peripheral neuropathy via Adenosine A2a receptors (A2aR). This suggests terpenes as potential non-opioid, non-cannabinoid therapeutics. In this study, we investigated post-operative and fibromyalgia pain, expanding potential terpene applications to different pain types.

METHODS

Male and female CD-1 mice had their baseline mechanical sensitivity measured via von Frey filaments and underwent either paw incision surgery or reserpine-induced fibromyalgia (0.32 mg/kg, sc). After pain was established, the mice received 200 mg/kg ip of a terpene, and their mechanical sensitivity was measured over three hours. To determine the potential mechanism of action, mice were given the A2aR antagonist istradefylline (3.2 mg/kg, ip) 10 min before terpene, with mechanical sensitivity measured after. Hot plate pain testing was performed as a control.

RESULTS

Terpene treatment caused time-dependent elevation of the mechanical thresholds of the mice from both pain models, strongest for geraniol, then linalool or α-humulene, indicating that these four terpenes are anti-nociceptive in post-surgical and fibromyalgia pain. Pretreatment with istradefylline blocked antinociception, suggesting the terpenes act via the A2aR in these pain models. Terpenes had no effect on hot plate latencies, ruling out non-specific motor effects.

CONCLUSIONS

These results demonstrate that the terpenes geraniol, linalool, β-caryophyllene, and α-humulene may be a viable medication for post-operative and fibromyalgia pain relief. Their mechanism of action via the A2aR furthers our knowledge of its importance in pain processing and as a target of terpene drugs.

Feasibility of an 8-Week Home-Based Sensory Perception Training Game for People with Fibromyalgia: A Pilot Study

People with fibromyalgia syndrome (FMS) may have difficulty attending rehabilitation sessions. We investigated the feasibility (adherence and satisfaction) of implementing an 8-week home-based somatosensory, entirely remote, self-training programme using the TrainPain smartphone app in people with FMS. The secondary aim was to evaluate the effect on pain symptoms. The training was performed 15 min/day, 7 days/week for 8 weeks. Participants identified the number of vibrations emitted by vibrotactile pods positioned on the most painful site and the contralateral side of the body. They completed the Brief Pain Inventory before, during (4 weeks), and at the end of the 8-week programme. At 8 weeks, they also rated satisfaction and the overall perceived change. The app recorded session completion. Of the 34 individuals recruited, 29 (mean, age 46 [SD] 9 years; 27 women; median duration of symptoms 7 [5;10] years) completed all assessments. Participants completed 75% of sessions and rated the programme easy-to-use and enjoyable, 94% would recommend the programme, and 38% reported a very strong improvement at 8 weeks. Pain intensity reduced from pre to post (effect size 0.77), as did interference (effect size 0.7 to 1.17). This treatment could be a useful addition to a multidisciplinary, multicomponent approach to FMS.

Effects of Traditional Chinese Martial Arts and Stretching Exercises on Symptoms of Fibromyalgia: A Systematic Review and Meta-Analysis

Fibromyalgia syndrome (FMS) is a chronic condition characterized by widespread musculoskeletal pain and various associated symptoms. Non-pharmacological interventions have gained attention for managing FMS and improving patient outcomes. We reviewed past research to investigate the effects of traditional Chinese martial arts (TCMA) and stretching training (ST) on symptoms of patients with FMS. We searched Web of Science, Medline via PubMed, the Cochrane Library, and EMBASE from their inceptions to June 1, 2023. Across selected studies, we evaluated TCMA and ST using Fibromyalgia Impact Questionnaire (FIQ) scores, pain symptoms, fatigue levels, and sleep quality as outcome measures. Compared with control groups, participants receiving TCMA and ST interventions showed significantly lower FIQ scores (Standard Mean Difference (SMD) = -3.01, 95% Confidence Interval (CI) [-4.83,-1.19]), improved pain symptoms (SMD = -0.77, 95% CI [-1.07,-0.47]), less fatigue (SMD = 1.31, 95% CI [0.50,2.11]), and enhanced sleep quality (SMD = -0.55, 95% CI [-0.97,-0.12]). Subgroup analyses revealed that, irrespective of intervention duration, both TCMA and ST interventions were effective in relieving pain symptoms in these patients. ST interventions showed significant improvement in fatigue symptoms, while TCMA interventions positively influenced sleep quality. These findings highlight potential non-pharmalogical benefits of TCMA and ST interventions in managing FMS. However, future research should explore the optimal duration, frequency, intensity, and types of interventions for TCMA and ST and design targeted exercise intervention programs to study the effects of these interventions on different characteristics of FMS patients. Attention should be given to the effects of short-term interventions on improving fatigue symptoms, sleep quality, and pain relief, to provide more personalized and effective FMS treatment plans.

The Effectiveness of the Low-Glycemic and Insulinemic (LOGI) Regimen in Maintaining the Benefits of the VLCKD in Fibromyalgia Patients

Background: Fibromyalgia (FM) is a chronic disorder that causes damage to the neuro-muscular system and alterations in the intestinal microbiota and affects the psychological state of the patient. In our previous study, we showed that 22 women patients subjected to a specific very low-carbohydrate ketogenic therapy (VLCKD) showed an improvement in clinical scores as well as neurotransmission-related and psychological dysfunctions and intestinal dysbiosis. Furthermore, NMR metabolomic data showed that changes induced by VLCKD treatment were evident in all metabolic pathways related to fibromyalgia biomarkers. Methods: Based on this evidence, we extend our investigation into dietary interventions for fibromyalgia by evaluating the impact of transitioning from a VLCKD to a low-glycemic insulinemic (LOGI) diet over an additional 45-day period. Therefore, participants initially following a VLCKD were transitioned to the LOGI diet after 45 days to determine whether the improvements in FM symptoms and metabolic dysfunctions achieved through VLCKD could be sustained with LOGI. Results: Our findings suggested that while VLCKD serves as an effective initial intervention for correcting metabolic imbalances and alleviating FM symptoms, transitioning to a LOGI diet offers a practical and sustainable dietary strategy. This transition preserves clinical improvements and supports long-term adherence and quality of life, underscoring the importance of adaptable nutritional therapies in chronic disease management. Control patients who adhered only to the LOGI diet for 90 days showed only modest improvement in clinical and psychological conditions, but not elimination of fibromyalgia symptoms. Conclusions: In conclusion the LOGI diet is an excellent alternative to maintain the results obtained from the regime VLCKD.

Electroacupuncture Regulates Cannabinoid Receptor 1 Expression in a Mouse Fibromyalgia Model: Pharmacological and Chemogenetic Modulation

Fibromyalgia is a chronic illness usually accompanied by long-lasting, general pain throughout the body, often accompanied by anxiety, depression, fatigue, and sleep disruption. Meanwhile, doctors and scientists have not entirely discovered detailed mechanisms; patients always have an exaggerated sensation to pervasive pain without satisfied medical service. Given the lack of knowledge on its underlying mechanism, current treatments aim to provide pain and/or symptom relief. The present study aimed to clarify the role of cannabinoid receptor 1 (CB1) signaling in a mouse fibromyalgia pain model. To develop the mouse fibromyalgia model, mice were subjected to intermittent cold stress (ICS). Our results indicated that mechanical (2.09 ± 0.09 g) and thermal hyperalgesia (4.77 ± 0.29 s), which were evaluated by von Frey and Hargraves' tests, were induced by ICS, suggesting successful modeling. The hurting replies were then provoked by electroacupuncture (EA) but not for sham EA mice. Further, in a Western blot analysis, we found significantly decreased CB1 protein levels in the thalamus, somatosensory cortex, and anterior cingulate cortex. In addition, the levels of pain-related protein kinases and transcription factor were increased. Treatment with EA reliably increased CB1 expression in various brain regions sequentially alleviated by nociceptive mediators. Furthermore, the administration of a CB1 agonist significantly attenuated fibromyalgia pain, reversed EA analgesia by the CB1 antagonist, and further reversed the chemogenetic inhibition of SSC. Our innovative findings evidence the role of CB1 signaling in the interaction of EA and fibromyalgia, suggesting its potential for clinical trials and as a treatment target.

Skeletal muscle relaxant for the treatment of fibromyalgia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/IMPORTANCE

Fibromyalgia is a complex chronic pain disorder that significantly impairs patient well-being. Evaluating the efficacy of muscle relaxants for treating fibromyalgia is crucial for improving patient care.

OBJECTIVE

This study aimed to evaluate the analgesic efficacy of muscle relaxants in patients with fibromyalgia.

EVIDENCE REVIEW

A comprehensive literature search was conducted using PubMed, EMBASE, Web of Science, ClinicalTrials.gov, and the Cochrane Library. The search included randomized controlled trials (RCTs) comparing skeletal muscle relaxants with placebo/active analgesics for fibromyalgia. The primary outcome was pain intensity, measured by standardized mean difference (SMD) in pain scores. The risk of bias of included RCTs was assessed using the Cochrane Risk of Bias Assessment Instrument for Randomized Controlled Trials.

FINDINGS

14 RCTs (1851 participants) were included. Muscle relaxants were associated with a small but statistically significant reduction in pain scores compared with placebo or active treatment (SMD=-0.24, 95% CI=-0.32 to -0.15, p<0.001, 95% prediction interval=-0.40 to -0.08), with no significant inconsistency (I2=0, 95% CI=0% to 50.79%) and a moderate Grading of Recommendation, Assessment, Development and Evaluation rating. Secondary outcomes showed small, but statistically significant improvements in depression, fatigue and sleep quality. Muscle relaxants were associated with increased incidence of overall adverse effects, fatigue, abnormal taste, and drug withdrawal due to adverse effects.

CONCLUSIONS

Moderate quality evidence showed that muscle relaxants were associated with a small reduction in pain intensity for patients with fibromyalgia.

Multimodal benefits of hypnosis on pain, mental health, sleep, and quality of life in patients with chronic pain related to fibromyalgia: A randomized, controlled, blindly-evaluated trial

BACKGROUND AND PURPOSE

Fibromyalgia is a chronic syndrome marked by intense musculoskeletal pain often refractory to pharmacological treatment. Although studies have shown that hypnosis improves fibromyalgia pain, gaps in experimental design limit their reliability. This work aimed to evaluate the effects of hypnosis on pain, mental health, sleep, and quality of life in participants with fibromyalgia chronic pain.

METHODS

In this prospective, parallel, randomized, controlled, blindly-evaluated trial, participants of both sexes (n = 49) diagnosed with fibromyalgia and with moderate to severe chronic pain attended 8 weekly 1-h sessions with a hypnotherapist. For the hypnosis group (n = 24), sessions consisted in induction of hypnotic trance followed by suggestions to promote analgesia. For the control group (n = 25), sessions consisted in casual unscripted conversation. Participants were assessed at baseline (7 days before), post-intervention (7 days after), and follow-up (3 months after). The primary outcome was pain intensity. The secondary outcomes were the sensory and affective dimensions of pain; pain unpleasantness; pain catastrophizing; anxiety and depression; sleep quality; fibromyalgia impact; and quality of life.

RESULTS

Hypnosis significantly reduced pain scores both at post-intervention and follow-up in comparison with baseline. The analgesic effect of hypnosis combined with pharmacological treatment lasted for at least 3 months and was superior to analgesia promoted by first- and second-line pharmacological treatment alone. Hypnosis significantly improved all parameters evaluated as secondary outcomes both at post-intervention and follow-up without inducing adverse events.

CONCLUSION

Our results corroborate that clinical hypnosis is an effective and feasible tool for managing chronic pain and other symptoms of fibromyalgia.

Efficacy and safety of low-dose naltrexone for the management of fibromyalgia: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

Background

Fibromyalgia is characterized by the presence of chronic widespread pain that may impair patient's quality of life. Currently, the use of naltrexone as a therapeutic agent for fibromyalgia is not supported by enough evidence, especially from randomized controlled trials (RCTs). This study aims to analyze the efficacy and safety of low-dose naltrexone (LDN) for the management of fibromyalgia.

Methods

A comprehensive search was conducted on the Scopus, Medline, ClinicalTrials.gov, and Cochrane Library databases up until May 20th, 2024. This review incorporates RCTs that examine the comparison between LDN and placebo in fibromyalgia patients. We employed random-effect models to analyze the odds ratio and mean difference (MD) for presentation of the outcomes.

Results

A total of 4 RCTs with 222 fibromyalgia patients were incorporated. The results of our meta-analysis showed a significant reduction in pain scores (MD: -0.86, 95% confidence interval [CI]: -1.20, -0.51, P < 0.001, I2 = 33%) and higher increment in pressure pain threshold (MD: 0.17, 95% CI: 0.08, 0.25, P < 0.001, I2 = 0%) among fibromyalgia patients who received LDN than those who only received a placebo. The fibromyalgia impact questionnaire revised and pain catastrophizing scale did not differ significantly between the two groups. LDN was also associated with higher incidence of vivid dreams and nausea, but showed no significant difference with the placebo in terms of serious adverse events, headache, diarrhea, and dizziness.

Conclusions

This study suggests the efficacy of LDN in mitigating pain symptoms for fibromyalgia patients with a relatively good safety profile.

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

Association of the Serotonin and Kynurenine Pathways as Possible Therapeutic Targets to Modulate Pain in Patients with Fibromyalgia

Fibromyalgia (FM) is a disorder characterized by widespread chronic pain, significant depression, and various neural abnormalities. Recent research suggests a reciprocal exacerbation mechanism between chronic pain and depression. In patients with FM, dysregulation of tryptophan (Trp) metabolism has been identified. Trp, an essential amino acid, serves as a precursor to serotonin (5-HT), a neuromodulator that influences mood, appetite, sleep, and pain perception through the receptors 5-HT1, 5-HT2, and 5-HT3. Additionally, Trp is involved in the kynurenine pathway, a critical route in the immune response, inflammation, and production of neuroactive substances and nicotinamide adenine dinucleotide (NAD+). The activation of this pathway by pro-inflammatory cytokines, such as tumor necrosis factor α (TNF-α) and interferon gamma (IFN-γ), leads to the production of kynurenic acid (KYNA), which has neuroprotective properties, and quinolinic acid (QA), which is neurotoxic. These findings underscore the crucial balance between Trp metabolism, 5-HT, and kynurenine, where an imbalance can contribute to the dual burden of pain and depression in patients with FM. This review proposes a novel therapeutic approach for FM pain management, focusing on inhibiting QA synthesis while co-administering selective serotonin reuptake inhibitors to potentially increase KYNA levels, thus dampening pain perception and improving patient outcomes.

Whole-Body Cryostimulation: An Effective Complementary Treatment in Fibromyalgia? A Follow Up Study

Recent evidence suggests that whole-body cryostimulation (WBC) may be beneficial for patients with fibromyalgia (FM), but little is known about the duration of such effects. The purpose of this study was to verify the duration of clinical-functional benefits after one cycle of WBC. We conducted a follow-up study on the medium and long-term effects of WBC on well-being, use of pain-relieving/anti-inflammatory medications, pain level, fatigue, sleep quality, and psychological aspects such as mood and anxiety. Twelve months after discharge, we administered a 10 min follow-up telephone interview with FM patients with obesity who had undergone ten 2 min WBC sessions at -110 °C as part of a multidisciplinary rehabilitation program (n = 23) and with patients who had undergone rehabilitation alone (n = 23). Both groups reported positive changes after the rehabilitation program, and similar results regarding fatigue, mood, and anxiety scores; however, the implementation of ten sessions of WBC over two weeks produced additional benefits in pain, general well-being status, and sleep quality with beneficial effects lasting 3-4 months. Therefore, our findings suggest that adding WBC to a rehabilitation program could exert stronger positive effects to improve key aspects of FM such as general well-being, pain level, and sleep quality.

Mind-body therapy for treating fibromyalgia: a systematic review

OBJECTIVE

Fibromyalgia is a chronic and disabling condition that presents management challenges for both patients and healthcare providers. The objective of this systematic review was to summarize current evidence on the effectiveness and safety of mind-body therapies in the treatment and/or management of fibromyalgia.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, AMED, and CINAHL databases from their inception to December 2023. Eligible articles included adults diagnosed with fibromyalgia participating in a mind-body therapy intervention and were published from the beginning of 2012 onwards. We assessed the quality of the studies using the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Of 3866 records screened, 27 studies (30 articles) met our inclusion criteria, in which 22 were randomized controlled trials and 5 were quasi-experimental studies. Mind-body therapies included guided imagery (n = 5), mindfulness-based stress reduction (n = 5), qi gong (n = 5), tai chi (n = 5), biofeedback (n = 3), yoga (n = 2), mindfulness awareness training (n = 1), and progressive muscle relaxation (n = 1). With the exception of mindfulness-based stress reduction, all therapies had at least one study showing significant improvements in pain at the end of treatment. Multiple studies on guided imagery, qi gong, and tai chi observed significant improvements in pain, fatigue, multidimensional function, and sleep. Approximately one-third of the studies reported on adverse events.

CONCLUSIONS

This review suggests that mind-body therapies are potentially beneficial for adults with fibromyalgia. Further research is necessary to determine if the positive effects observed post-intervention are sustained.

STUDY REGISTRATION

Open Science Framework (https://osf.io) (September 12, 2023; https://doi.org/10.17605/osf.io/6w7ac).

Fibromyalgia pathogenesis explained by a neuroendocrine multistable model

Fibromyalgia (FM) is a central disorder characterized by chronic pain, fatigue, insomnia, depression, and other minor symptoms. Knowledge about pathogenesis is lacking, diagnosis difficult, clinical approach puzzling, and patient management disappointing. We conducted a theoretical study based on literature data and computational analysis, aimed at developing a comprehensive model of FM pathogenesis and addressing suitable therapeutic targets. We started from the evidence that FM must involve a dysregulation of central pain processing, is female prevalent, suggesting a role for the hypothalamus-pituitary-gonadal (HPG) axis, and is stress-related, suggesting a role for the HP-adrenocortical (HPA) axis. Central pathogenesis was supposed to involve a pain processing loop system including the thalamic ventroposterolateral nucleus (VPL), the primary somatosensory cortex (SSC), and the thalamic reticular nucleus (TRN). For decreasing GABAergic and/or increasing glutamatergic transmission, the loop system crosses a bifurcation point, switching from monostable to bistable, and converging on a high-firing-rate steady state supposed to be the pathogenic condition. Thereafter, we showed that GABAergic transmission is positively correlated with gonadal-hormone-derived neurosteroids, notably allopregnanolone, whereas glutamatergic transmission is positively correlated with stress-induced glucocorticoids, notably cortisol. Finally, we built a dynamic model describing a multistable, double-inhibitory loop between HPG and HPA axes. This system has a high-HPA/low-HPG steady state, allegedly reached in females under combined premenstrual/postpartum brain allopregnanolone withdrawal and stress condition, driving the thalamocortical loop to the high-firing-rate steady state, and explaining the connection between endocrine and neural mechanisms in FM pathogenesis. Our model accounts for FM female prevalence and stress correlation, suggesting the use of neurosteroid drugs as a possible solution to currently unsolved problems in the clinical treatment of the disease.

Management of Fibromyalgia: An Update

Fibromyalgia, a chronic pain condition marked by abnormal pain processing, impacts a significant part of the population, leading to reduced quality of life and function. Hallmark symptoms include widespread persistent pain, sleep disturbances, fatigue, cognitive dysfunction, and mood changes. Through this updated review, we aim to contribute to the evolving understanding and management of fibromyalgia, offering insights into the diverse tools available to improve the lives of those affected by this challenging condition. Management begins with educating patients to ultimately relieve them of unnecessary testing and provide reassurance. Treatment emphasizes a comprehensive approach, combining nonpharmacological interventions such as aforementioned education, exercise, and psychotherapy, alongside pharmacologic management-namely duloxetine, milnacipran, pregabalin, and amitriptyline-which have consistent benefits for a range of symptoms across the spectrum of fibromyalgia. Notably, drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are generally not recommended due to limited efficacy and associated risks. Lastly, a variety of other medications have shown promise, including NMDA-receptor antagonists, naltrexone, and cannabinoids; however, they should be used with caution due to a small amount of evidence and potential for adverse effects.

Perimenopause in women with rheumatologic diseases: a spotlight on an under-addressed transition

Abundant research has been published describing the effects invoked during menopause across different organ systems. Changing levels of estrogen and progesterone result in bidirectional alterations of immune cell pathways. Overall, the net trend dampens immunoregulation and promotes inflammation. In paradigmatic rheumatologic diseases, the combined effect is far from predictable. While some features may abate during menopause, studies have shown a general increased frequency toward disease exacerbation. Similarly, while impossible to isolate the ramifications of menopause in women with fibromyalgia, a tendency toward enhanced symptoms is unquestionably apparent. Furthermore, the comorbidities accrued by increasing age and the consequences of long-term medication use may also confound this picture. Periodic rheumatologic visits are warranted, with clinical assessments directed toward a multi-disciplinary approach. Ultimately, while an arsenal of effective tools is available for caring for these women and their underlying conditions, more studies are needed to better clarify how the different stages surrounding perimenopause affect subpopulations with rheumatic diseases and fibromyalgia-related disorders so that clinical course can be predicted and addressed prior to the emergence of symptomatology.

Do FIQR Severity Categories and Symptoms, Differentiate Between Continuous, Intermittent and Non-Opioid Users in the Treatment of Fibromyalgia?

BACKGROUND

Many fibromyalgia patients utilize opioids to treat symptoms. It is important to better understand nuances regarding this treatment option and any stigma associated with this treatment modality.

AIM

This study: (1) assessed the prevalence of opioid use among continuous, intermittent, and non-opioid users in fibromyalgia patients; (2) determined whether the Revised Fibromyalgia Impact Questionnaire (FIQR) was useful in distinguishing opioid use and symptom burden; and (3) assessed whether fibromyalgia patients encountered stigma and/or invalidation.

DESIGN

A cross-sectional, observational study of 1,105 participants' responses to validated fibromyalgia and invalidation scales and demographic questions.

METHODS

The study employed online survey methodology.

RESULTS

A total of 45% of patients reported utilizing opioids (27% continuous, 18% intermittent, 55% non-users). FIQR disease categories (mild to most severe) strongly distinguished between opioid and non-opioid users with 59% of users falling in the most severe category and 68% of non-users falling in mild disease category (p < .0001). Interestingly, intermittent users were similar to non-users on FIQR severity (65.9 versus 65.7; p <0.60, 0-100) while continuous users reported greater severity than the former (73.9, p < .0001). Continuous users particularly reported more problems with daily activities (p < .0001), being overwhelmed (p < .0001), and being unable to accomplish goals (p < .0001). Stigma related to being 'drug seeking' and being 'judged'. Invalidation was infrequent.

CONCLUSIONS

Opioid use is common in fibromyalgia and increases monotonically with FIQR severity. Multidisciplinary approaches which help patients perform daily activities, decrease feelings of overwhelm, accomplish goals, and reduce stigma may be beneficial.

Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study

OBJECTIVE

Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up.

STUDY DESIGN

A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable.

RESULTS

The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroid was 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively. Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative and positive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05.

CONCLUSION

Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

Exploring the Relationship between Diamine Oxidase and Psychotropic Medications in Fibromyalgia Treatment, Finding No Reduction in Diamine Oxidase Levels and Activity except with Citalopram

Background: Histamine intolerance manifests when there is an imbalance between the production of histamine and the body's capacity to metabolise it. Within the gastrointestinal tract, diamine oxidase (DAO) plays a pivotal role in breaking down ingested histamine. Insufficient levels of DAO have been linked to various diseases affecting the respiratory, cardiovascular, nervous, muscular, and digestive systems; some of these symptoms are evidenced in fibromyalgia syndrome. This underscores the crucial role of DAO in maintaining the histamine balance and highlights its association with diverse physiological systems and health conditions. The management of fibromyalgia commonly involves the use of psychotropic medications; however, their potential interactions with DAO remain not fully elucidated. Methods: This study delved into the influence of various psychotropic medications on DAO activity through in vitro experiments. Additionally, we explored their impact on the human intestinal cell line Caco-2, examining alterations in DAO expression at both the mRNA and protein levels along with DAO activity. Results: Notably, the examined drugs-sertraline, pregabalin, paroxetine, alprazolam, and lorazepam-did not exhibit inhibitory effects on DAO activity or lead to reductions in DAO levels. In contrast, citalopram demonstrated a decrease in DAO activity in in vitro assays without influencing DAO levels and activity in human enterocytes. Conclusions: These findings imply that a collaborative approach involving psychotropic medications and DAO enzyme supplementation for individuals with fibromyalgia and a DAO deficiency could offer potential benefits for healthcare professionals in their routine clinical practice.

Naltrexone 6 mg once daily versus placebo in women with fibromyalgia: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Low-dose naltrexone is used to treat fibromyalgia despite minimal evidence for its efficacy. This trial aimed to investigate whether 12-week treatment with 6 mg low-dose naltrexone was superior to placebo for reducing pain in women with fibromyalgia.

METHODS

We did a single-centre, randomised, double-blind, placebo-controlled trial in Denmark. We enrolled women aged 18-64 years who were diagnosed with fibromyalgia. Participants were randomly assigned 1:1 to receive low-dose naltrexone (6 mg) or an identical-appearing placebo, using a computerised algorithm with no stratifications applied. Participants, investigators, outcome assessors, and statistical analysts were all masked to treatment allocation. The primary outcome was change in pain intensity on an 11-point numeric rating scale from baseline to week 12, in the intention-to-treat population. Safety was assessed in participants in the intention-to-treat population who received at least one dose of their allocated intervention. This trial was registered with ClincalTrials.gov (NCT04270877) and EudraCT (2019-000702-30).

FINDINGS

We screened 158 participants for eligibility from Jan 6, 2021, to Dec 27, 2022, and 99 patients were randomly assigned to low-dose naltrexone (n=49) or placebo (n=50). The mean age was 50·6 years (SD 8·8), one (1%) of 99 participants was Arctic Asian and 98 (99%) were White. No participants were lost to follow-up. The mean change in pain intensity was -1·3 points (95% CI -1·7 to -0·8) in the low-dose naltrexone group and -0·9 (-1·4 to -0·5) in the placebo group, corresponding to a between-group difference of -0·34 (-0·95 to 0·27; p=0·27, Cohen's d 0·23). Discontinuations due to adverse events were four (8%) of 49 in the low-dose naltrexone group and three (6%) of 50 in the placebo group. 41 (84%) of 49 patients in the low-dose naltrexone group had an adverse event versus 43 (86%) of 50 in the placebo group. One serious adverse event occurred in the placebo group and no deaths occurred.

INTERPRETATION

This study did not show that treatment with low-dose naltrexone was superior to placebo in relieving pain. Our results indicate that low-dose naltrexone might improve memory problems associated with fibromyalgia, and we suggest that future trials investigate this further.

FUNDING

The Danish Rheumatism Association, Odense University Hospital, Danielsen's Foundation, and the Oak Foundation.

Recognizing and Treating Major Depression in Fibromyalgia: A Narrative Primer for the Non-Psychiatrist

Fibromyalgia (FM) affects 2% to 8% of the general population. FM patients often experience self-stigma and feel rejected by healthcare providers and families, resulting in isolation and distressing symptoms of pain, fatigue, and poor cognitive functioning, increasing the risk of depressive symptoms. Major Depressive Disorder (MDD) is the most common comorbidity in FM patients (Any depression: 43%; MDD: 32%). Genome-wide association studies (GWAS) have identified a common genetic risk loci for major depression and fibromyalgia. Given that even minor symptoms of depression worsen the outcomes of FM patients, clinicians are challenged to identify and manage depression in these patients. However, due to overlapping symptoms, limited screening, and contamination bias, MDD often goes undiagnosed and presents a critical challenge. Unrecognized and untreated MDD in FM patients can exacerbate fatigue, sleep disturbances, and pain, reduce physical functioning, and increase the risk of developing comorbid conditions, such as substance abuse and cardiovascular disease. These comorbidities are associated with a lower treatment response rate, a higher dropout rate, and a greater risk of relapse. Clinicians may effectively identify and treat MDD in FM patients with appropriate pharmacologic agents combined with aerobic exercise and cognitive-behavioral therapies for core FM symptoms, thus significantly reducing symptom severity for both MDD and FM. Such a comprehensive approach will result in a much-improved quality of life. MedLine content was searched via PubMed to identify eligible articles between 1995 and 2023 using search terms fibromyalgia, major depressive disorder, and treatment of depression in fibromyalgia, and the most current information is presented. In this primer for clinicians caring for FM patients, we describe clinically relevant pharmacologic and non-pharmacologic management approaches for treating MDD in FM patients.

Fibromyalgia Animal Models Using Intermittent Cold and Psychological Stress

Fibromyalgia (FM) is a chronic pain condition characterized by widespread musculoskeletal pain and other frequent symptoms such as fatigue, sleep disturbance, cognitive impairment, and mood disorder. Based on the view that intermittent stress would be the most probable etiology for FM, intermittent cold- and intermittent psychological stress-induced generalized pain (ICGP and IPGP) models in mice have been developed and validated as FM-like pain models in terms of the patho-physiological and pharmacotherapeutic features that are shared with clinical versions. Both models show long-lasting and generalized pain and female-predominant sex differences after gonadectomy. Like many other neuropathic pain models, ICGP and IPGP were abolished in lysophosphatidic acid receptor 1 (LPAR1) knock-out mice or by LPAR1 antagonist treatments, although deciding the clinical importance of this mechanism depends on waiting for the development of a clinically available LPAR1 antagonist. On the other hand, the nonsteroidal anti-inflammatory drug diclofenac with morphine did not suppress hyperalgesia in these models, and this is consistent with the clinical findings. Pharmacological studies suggest that the lack of morphine analgesia is associated with opioid tolerance upon the stress-induced release of endorphins and subsequent counterbalance through anti-opioid NMDA receptor mechanisms. Regarding pharmacotherapy, hyperalgesia in both models was suppressed by pregabalin and duloxetine, which have been approved for FM treatment in clinic. Notably, repeated treatments with mirtazapine, an α2 adrenergic receptor antagonist-type antidepressant, and donepezil, a drug for treating Alzheimer's disease, showed potent therapeutic actions in these models. However, the pharmacotherapeutic treatment should be carried out 3 months after stress, which is stated in the FM guideline, and many preclinical studies, such as those analyzing molecular and cellular mechanisms, as well as additional evidence using different animal models, are required. Thus, the ICGP and IPGP models have the potential to help discover and characterize new therapeutic medicines that might be used for the radical treatment of FM, although there are several limitations to be overcome.

Assessing Ethnic Minority Representation in Fibromyalgia Clinical Trials: A Systematic Review of Recruitment Demographics

The under-representation of non-White participants in Western countries in clinical research has received increased attention, due to recognized physiological differences between ethnic groups, which may affect the efficacy and optimal dosage of some treatments. This review assessed ethnic diversity in pharmaceutical trials for fibromyalgia, a poorly understood chronic pain disorder. We also investigated longitudinal change to non-White participant proportions in trials and non-White participants' likelihood to discontinue with fibromyalgia research between trial stages (retention). First, we identified relevant trials conducted in the United States and Canada between 2000 and 2022, by searching PubMed, Web of Science, Scopus, and the Cochrane Library databases. In trials conducted both across the United States and Canada, and exclusively within the United States, approximately 90% of participants were White. A longitudinal analysis also found no change in the proportion of non-White participants in trials conducted across the United States and Canada between 2000 and 2022. Finally, we found no significant differences in trial retention between White and non-White participants. This review highlights the low numbers of ethnic minorities in fibromyalgia trials conducted in the United States and Canada, with no change to these proportions over the past 22 years. Furthermore, non-White participants were not more likely to discontinue with the fibromyalgia research once they were recruited.

Effectiveness of traditional Chinese exercise in patients with fibromyalgia syndrome: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND OBJECTIVE

Fibromyalgia syndrome (FMS) is a common disorder characterized by heterogeneous symptoms that leads to decreased functioning, work productivity, and quality of life. Exercise has been recommended for fibromyalgia treatment. Traditional Chinese exercise (TCE), including Taichi, Qigong, Badunjin, Wuqinxi, etc., as a kind of mind-body exercise, plays an important role in alleviating symptoms of FMS. The objective of this study is to summarize the available evidence, through meta-analysis, on the pain relief, quality of life, sleep improvement, and emotion regulation of FMS in TCE.

METHODS

Databases of PubMed, EMBASE, Cochrane library, Google scholar, CNKI, WANFANG DATA, VIP, etc. were used to search eligible studies that were published from the time of their inception to February 11, 2022, in English and Chinese. The included studies were divided into two groups: TCE group (experimental group) and control group. The Cochrane collaboration's tool was used to assess the risk of bias, and Revman5.4.1 software was used to synthesize and analyze the data.

RESULTS

A total of 12 literatures were included in this study, which contained 781 patients, and 448 of them were included in the treatment group, 333 of others in control group. TCE significantly alleviated pain [SMD = -0.83, 95% CI (-1.15, -0.51), p < .00001], improved quality of life [SMD = -0.53, 95% CI (-0.86, -0.19), p = .002] and improved qualities of sleep [SMD = -0.41, 95% CI (-0.57, -0.24), p < .00001] and relieved depression [SMD = -0.40, 95% CI (-0.69, -0.10), p < .008].

CONCLUSION

TCE may be a way to reduce pain, improve the quality of life and sleep, and relieve depression for FMS, and it could be part of the FMS treatment.

Low-dose naltrexone's utility for non-cancer centralized pain conditions: a scoping review

BACKGROUND

At low doses, naltrexone (LDN) has been shown to modulate inflammation through the interruption of microglial cell activation within the central nervous system. One of the most likely contributors to centralized pain is changes in microglial cell processing. Therefore, it has been postulated that LDN can be used to manage patients with pain resulting from central sensitization due to this relationship. This scoping review aims to synthesize the relevant study data for LDN as a novel treatment strategy for various centralized pain conditions.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, and Google Scholar, guided by the Scale for Assessment of Narrative Review Articles (SANRA) criteria.

RESULTS

Forty-seven studies related to centralized pain conditions were identified. Many of the studies were case reports/series and narrative reviews, but a few randomized control trials have been conducted. Overall, the body of evidence revealed improvement in patient-reported pain severity and in outcomes related to hyperalgesia, physical function, quality of life, and sleep. Variability in dosing paradigms and the time to patient response was present in the reviewed studies.

CONCLUSIONS

Evidence synthesized for this scoping review supports the ongoing use of LDN for the treatment of refractory pain in various centralized chronic pain conditions. Upon review of the currently available published studies, it is apparent that further high-quality, well-powered randomized control trials need to be conducted to establish efficacy, standardization for dosing, and response times. In summary, LDN continues to offer promising results in the management of pain and other distressing symptoms in patients with chronic centralized pain conditions.

[Fibromyalgia as a Rheumatic Pain Syndrome]

Epidemiology and pathophysiology: Fibromyalgia is significantly more common in people with rheumatic diseases than in the general population. Nevertheless, it can occur independent of other diseases. Physical and psychosocial factors are responsible for the genesis for fibromyalgia making it a multifactorial disease. Most importantly, central pain processing seems to be abnormal. The relevance of a small fibre neuropathy is yet to be determined. For the very first time, a study was able to demonstrate that fibromyalgia might be passively transferred from one organism to another in an experimental setting.Diagnosis: Fibromyalgia is a clinical diagnose. Besides generalized pain, sleep disturbances and fatigue are common features. Furthermore, there can be an association with depressive disorders. Determining the Widespread Pain Index (WPI) and the Symptom Severity Score (SSS) can help in diagnosing Fibromyalgia and to determine severity of the disease.Therapy: Cornerstones of the treatment are patient education, physical exercise, physical therapy, and cognitive behavioural therapy. In therapy-resistant cases, a multimodal approach might be considered. Analgesic drugs, particularly opioids, should basically be avoided or only be used for a short period of time. Naltrexone, an opioid antagonist, is a promising treatment candidate. Another possible approach might be the use of TENS. While there are positive observational studies on the therapeutic use of cannabinoids, evidence from controlled trials is still missing.

Body reprogramming for fibromyalgia and central sensitivity syndrome: A preliminary evaluation

Objectives

Central sensitivity syndrome disorders such as fibromyalgia, provoke continued debate, highlighting diagnostic and therapeutic uncertainty. The Hyland model provides a way of understanding and treating the medically unexplained symptoms of central sensitivity syndromes using complexity theory and principles of adaption in network systems. The body reprogramming is a multi-modal intervention based on the Hyland model designed for patients living with medically unexplained symptoms. This preliminary, naturalistic and single-arm service evaluation set out to evaluate outcome after attending a body reprogramming course in patients living with fibromyalgia or central sensitivity syndrome.

Methods

Patients diagnosed with fibromyalgia or central sensitivity syndrome were recruited. The body reprogramming courses consisting of eight sessions, each 2.5 h in length, were run at two study sites in England. Data were collected at baseline, post course and 3-months post course using questionnaires assessing symptomatology (FIQR/SIQR), Depression (PHQ9), Anxiety (GAD7) and quality of life (GQoL). Repeated measures t-tests were used, and all comparisons were conducted on an intention to treat basis.

Results

In total, 198 patients with a mean age of 47.73 years were enrolled on the body reprogramming courses. Statistically and clinically significant improvement were observed in the FIQR from baseline to post course (mean change: 11.28) and baseline to follow-up (mean change: 15.09). PHQ9 scores also improved significantly from baseline to post course (mean reduction 3.72) and baseline to follow-up (mean reduction 5.59).

Conclusions

Our study provides first evidence that the body reprogramming intervention is an effective approach for patients living with fibromyalgia or central sensitivity syndromes on a variety of clinical measures. Besides these promising results, important limitations of the study are discussed, and larger randomized controlled trials are clearly warranted.

Neural indices of multimodal sensory and autonomic hyperexcitability in fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread musculoskeletal pain and psychological distress. Research suggests people with FM experience increased somatosensory sensitization which generalizes to other sensory modalities and may indicate neural hyperexcitability. However, the available evidence is limited, and studies including measures of neural responsivity across sensory domains and both central and peripheral aspects of the neuraxis are lacking. Thirty-nine participants (51.5 ± 13.6 years of age) with no history of neurological disorders, psychosis, visual, auditory, or learning deficits, were recruited for this study. People with FM (N = 19) and control participants (CNT, N = 20) did not differ on demographic variables and cognitive capacity. Participants completed a task that combined innocuous auditory stimuli with electrocutaneous stimulation (ECS), delivered at individually-selected levels that were uncomfortable but not painful. Event-related potentials (ERPs) and electrodermal activity were analyzed to examine the central and sympathetic indices of neural responsivity. FM participants reported greater sensitivity to ECS and auditory stimulation, as well as higher levels of depression, anxiety, ADHD, and an array of pain-related experiences than CNT. In response to ECS, the P50 deflection was greater in FM than CNT participants, reflecting early somatosensory hyperexcitability. The P50 amplitude was positively correlated with the FM profile factor obtained with a principal component analysis. The N100 to innocuous tones and sympathetic reactivity to ECS were greater in FM participants, except in the subgroup treated with gabapentinoids, which aligns with previous evidence of symptomatic improvement with GABA-mimetic medications. These results support the principal tenet of generalized neural hyperexcitability in FM and provide preliminary mechanistic insight into the impact of GABA-mimetic pharmacological therapy on ameliorating the neural excitation dominance.

Duloxetine for fibromyalgia syndrome: a systematic review and meta-analysis

INTRODUCTION

The optimal dose of duloxetine in the management of fibromyalgia remains still controversial. Therefore, a systematic review and meta-analysis to investigate efficacy and safety of duloxetine was conducted. The outcomes of interests were to assess changes in Fibromyalgia Impact Questionnaire (FIQ), Brief Pain Inventory (BPI), and Clinical Global Impression (CGI). The rate of of adverse events and those leading to therapy discontinuation were also investigated.

MATERIAL AND METHODS

This study followed the 2020 PRISMA guidelines. The literature search started in December 2022 accessing PubMed, Google scholar, Embase, and Scopus databases. All the RCTs investigating the efficacy and safety of daily administration of duloxetine for fibromyalgia were accessed. Studies reporting quantitative data under the outcomes of interest, and including a minimum of 10 patients who completed a minimum of 4 weeks follow-up, were included. Studies on combined pharmacological and non-pharmacological managements for fibromyalgia were not considered.

RESULTS

Data from 3432 patients (11 RCTs) were included. The mean age of the patients was 46.4 ± 10.7 years old, and the mean BMI 25.3 ± 3.2 kg/m². 90% (3089 of 3432 patients) were women. The 60 mg/daily cohort reported the higher FIQ, followed by the 30, 30-60, 120 mg/daily, and placebo groups, while the 60-120 mg /daily group performed the worst results. Concerning the CGI severity scale, placebo resulted in the lowest improvement, and no differences were found in the other groups. Concerning the BPI interference and severity pain scores, the 30-60 mg/daily group reported the worst result, along with the placebo group. The rate of adverse events leading to study discontinuation were lower in the 60-120 group, followed by the 30-60 and 30 mag/daily groups. Duloxetine was superior in all the comparisons to placebo, irrespective of the doses, in all endpoints analysed.

CONCLUSIONS

Duloxetine could help in improving symptoms of fibromyalgia. The dose of duloxetine should be customised according to individual patients. Irrespective of the doses, duloxetine was more effective than placebo in the management of fibromyalgia. The dose of duloxetine must be customised according to individual patients. Level of evidence I Meta-analysis of double-blind RCTs.

Pain Biomarkers in Fibromyalgia Syndrome: Current Understanding and Future Directions

Fibromyalgia is a complex and heterogeneous clinical syndrome, mainly characterized by the presence of widespread pain, possibly associated with a variety of other symptoms. Fibromyalgia can have an extremely negative impact on the psychological, physical and social lives of people affected, sometimes causing patients to experience dramatically impaired quality of life. Nowadays, the diagnosis of fibromyalgia is still clinical, thus favoring diagnostic uncertainties and making its clear identification challenging to establish, especially in primary care centers. These difficulties lead patients to undergo innumerable clinical visits, investigations and specialist consultations, thus increasing their stress, frustration and even dissatisfaction. Unfortunately, research over the last 25 years regarding a specific biomarker for the diagnosis of fibromyalgia has been fruitless. The discovery of a reliable biomarker for fibromyalgia syndrome would be a critical step towards the early identification of this condition, not only reducing patient healthcare utilization and diagnostic test execution but also providing early intervention with guideline-based treatments. This narrative article reviews different metabolite alterations proposed as possible biomarkers for fibromyalgia, focusing on their associations with clinical evidence of pain, and highlights some new, promising areas of research in this context. Nevertheless, none of the analyzed metabolites emerge as sufficiently reliable to be validated as a diagnostic biomarker. Given the complexity of this syndrome, in the future, a panel of biomarkers, including subtype-specific biomarkers, could be considered as an interesting alternative research area.

Diagnosis and Management of Neuropathic Pain in Spine Diseases

Neuropathic pain is generally defined as a non-physiological pain experience caused by damage to the nervous system. It can occur spontaneously, as a reaction to a given stimulus, or independently of its action, leading to unusual pain sensations usually referred to as firing, burning or throbbing. In the course of spine disorders, pain symptoms commonly occur. According to available epidemiological studies, a neuropathic component of pain is often present in patients with spinal diseases, with a frequency ranging from 36% to 55% of patients. Distinguishing between chronic nociceptive pain and neuropathic pain very often remains a challenge. Consequently, neuropathic pain is often underdiagnosed in patients with spinal diseases. In reference to current guidelines for the treatment of neuropathic pain, gabapentin, serotonin and norepinephrine reuptake inhibitors and tricyclic antidepressants constitute first-line therapeutic agents. However, long-term pharmacologic treatment often leads to developing tolerance and resistance to used medications. Therefore, in recent years, a plethora of therapeutic methods for neuropathic pain have been developed and investigated to improve clinical outcomes. In this review, we briefly summarized current knowledge about the pathophysiology and diagnosis of neuropathic pain. Moreover, we described the most effective treatment approaches for neuropathic pain and discussed their relevance in the treatment of spinal pain.

Review of Fibromyalgia (FM) Syndrome Treatments

BACKGROUND

Fibromyalgia (FM) is a disease characterized by widespread musculoskeletal chronic pain that impairs the patient's quality of life and is considered a somatization disorder. The symptoms of the disease also affect the patient mentally, mainly since invisible pain is the only thing that indicates its existence. A typical symptom that characterizes FM patients is the lack of acceptance of the disease since its pathophysiology is not elucidated, hence the deficiencies in its management, or rather, cognitively, the belief that there is no disease to manage. The current paper aims to shed light on the new treatment methods at a holistic level, that is, cognitive, physical, and pharmacological therapies.

METHOD

A literature review was carried out that discusses treatment methods that help alleviate the pain, accept it, and manage the symptoms of the disease.

RESULTS

FM symptoms can be treated by taking a broad view of treatment that will include a response to the mind through pain management, response to the body through physical activity, and response to the pain through pharmacological treatment.

CONCLUSIONS

Today, there is an evolutionary view that accepts FM and chronic pain diseases as syndromes in which the pain is the disease; therefore, the response to this disease can be applied through three channels: physical, bodily, and mental.

Pregabalin administration in patients with fibromyalgia: a Bayesian network meta-analysis

Several studies investigated the effectiveness and the safety of different doses of pregabalin in fibromyalgia. However, the optimal protocol remains controversial. A Bayesian network meta-analysis comparing 300, 450, and 600 mg/daily of pregabalin for fibromyalgia was conducted. The literature search was conducted in January 2022. All the double-blind randomised clinical trials comparing two or more dose protocols of pregabalin for fibromyalgia were accessed. Studies enrolling less than 50 patients were not eligible, nor were those with a length of follow-up shorter than eight weeks. The outcomes of interests were: Fibromyalgia Impact Questionnaire (FIQ), sleep quality, and adverse events. The network meta-analyses were performed using the routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) and standardized mean difference (SMD) effect measure. Data from 4693 patients (mean age 48.5 years) were retrieved. 93.1% (4370 of 4693 patients) were women. The median follow-up was 14.8 weeks. Pregabalin 450 mg/daily resulted in greater reduction in Fibromyalgia Impact Questionnaire (SMD - 1.83). Pregabalin 600 demonstrated the greatest sleep quality (SMD 0.15). Pregabalin 300 mg/daily evidenced the lowest rate of adverse events (LOR 0.12). The dose of pregabalin must be customised according to patients' characteristics and main symptoms.

Thalamocortical bistable switch as a theoretical model of fibromyalgia pathogenesis inferred from a literature survey

Fibromyalgia (FM) is an unsolved central pain processing disturbance. We aim to provide a unifying model for FM pathogenesis based on a loop network involving thalamocortical regions, i.e., the ventroposterior lateral thalamus (VPL), the somatosensory cortex (SC), and the thalamic reticular nucleus (TRN). The dynamics of the loop have been described by three differential equations having neuron mean firing rates as variables and containing Hill functions to model mutual interactions among the loop elements. A computational analysis conducted with MATLAB has shown a transition from monostability to bistability of the loop behavior for a weakening of GABAergic transmission between TRN and VPL. This involves the appearance of a high-firing-rate steady state, which becomes dominant and is assumed to represent pathogenic pain processing giving rise to chronic pain. Our model is consistent with a bulk of literature evidence, such as neuroimaging and pharmacological data collected on FM patients, and with correlations between FM and immunoendocrine conditions, such as stress, perimenopause, chronic inflammation, obesity, and chronic dizziness. The model suggests that critical targets for FM treatment are to be found among immunoendocrine pathways leading to GABA/glutamate imbalance having an impact on the thalamocortical system.

Nociplastic pain concept, a mechanistic basis for pragmatic approach to fibromyalgia

Nociplastic pain (NP), as a mechanistic term, denotes pain arising from altered nociception without clear evidence of tissue or somatosensory damage. Fibromyalgia (FM), a prototypical NP condition, incorporates a broad continuum of phenotypes with a distinct neurobiological signature and shared NP attributes. The nociplastic concept may provide a new opportunity for early diagnosis of FM by identifying the characteristic NP features before a state of pain generalization and symptoms clustering. In this approach, even individual symptoms associated with NP features are worthy of attention to denote FM. It may provide a timely diagnosis of FM before clinical progression to a severe and hard-to-manage condition. Furthermore, collecting all various FM phenotypes under the nociplastic concept and not delimiting FM to the only typical presentation allows investigators to identify FM subgroups reflecting potentially distinct pathophysiologic mechanisms and biomarkers. This viewpoint can be served in future studies to develop individualized management. In this review, we postulate a novel approach to early FM diagnosis and management based on NP conceptualization and phenotype recognition. Key Points • FM as a NP condition represents overlapping clinical phenotypes and incomplete presentations especially in early stage of illness. • The mechanistic approach based on the NP features of FM can be implicated in the timely diagnosis and management of FM. • The NP-based approach to FM provides a broader viewpoint beyond FM delimitation to pain generalization and polysymptomatic complaints.

An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review

Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.

Depression in Fibromyalgia Patients May Require Low-Dose Naltrexone to Respond: A Case Report

Fibromyalgia and depression are frequently comorbid. We propose a hormonal system model in understanding the underlying endogenous opioid system dysregulation in fibromyalgia with the utilization of the cold pressor test (CPT) in clinical practice to monitor treatment response to low-dose naltrexone (LDN) and the subsequent remission of major depressive disorder by restoring opioid tone.

A 60-year-old professional on permanent disability presented with refractory depression and chronic widespread pain after years of multiple failed medication trials. Rating scales confirmed severe depression, Hamilton Rating Scale for Depression (HAM-D) of 20, a short cold pressor test (CPT) time of 21 seconds, and a face pain scale (FPS) of 8/10. Physical examination assessing for fibromyalgia was diagnostic, with 18/18 positive tender points.

LDN, a minor increase in trazodone, and transference-focused psychotherapy were employed. The patient’s CPT time increased modestly. The patient achieved remission of both conditions in 10 weeks when both disorders were treated at once (FPS and HAM-D of zero), restoring the quality of life, relatedness, and motivation.

Some fibromyalgia patients may achieve remission of comorbid depression with concomitant low-dose naltrexone (LDN) treatment that is widely used “off label” to treat pain. LDN is a promising alternative for the treatment of chronic pain in fibromyalgia with its safety profile, high tolerability, and absence of abuse potential. Our unique finding is that without successful LDN treatment of fibromyalgia, remission of depression may be unlikely.

Milnacipran for the Treatment of Fibromyalgia

Purpose of review

This is a comprehensive review of the literature regarding the use of milnacipran in treating fibromyalgia. A chronic pain disorder with other system disturbances, fibromyalgia is often resistant to many therapeutic approaches. This review presents the background, evidence, and indications for using milnacipran as a treatment option for this condition.

Recent Findings

The definition of fibromyalgia has evolved over many years as it is a relatively tricky syndrome to measure objectively. Today, it is characterized by chronic, widespread pain accompanied by alterations in sleep, mood, and other behavioral aspects. A variety of therapeutic regimens currently used to treat the syndrome as a singular approach are rarely effective.Milnacipran is one of three drugs currently approved by the FDA for the treatment of fibromyalgia. It acts as a serotonin and norepinephrine reuptake inhibitor, which results in decreased pain transmission. Milnacipran remains an effective treatment option for fibromyalgia in adults and needs to be further evaluated with existing therapeutic approaches.

Summary

Fibromyalgia is a broad-spectrum disorder primarily characterized by chronic pain coupled with disturbances in cognitive functioning and sleep. The progression of this syndrome is often debilitating and significantly affects the quality of life. Milnacipran is one of three FDA-approved drugs used to alleviate the symptom burden and is comparatively more therapeutic in specific domains of fibromyalgia. A more holistic approach is needed to treat fibromyalgia effectively and further research, including direct comparison studies, should be conducted to fully evaluate the usefulness of this drug.

A Systematic Review of Fibromyalgia and Recent Advancements in Treatment: Is Medicinal Cannabis a New Hope?

Fibromyalgia syndrome (FMS) is a pain disorder characterized by chronic widespread pain, fatigue, and sleep disturbance, in the absence of any well-defined underlying organic disease. The exact pathophysiology and the mechanism which links different factors related to the disease is still unknown. Due to unknown precise pathogenesis, the coexistence of other diseases, and overlapping clinical features, FMS diagnosis may be laborious. Various treatment strategies are used, only a few Food and Drug Administration (FDA) approved, still we are facing challenges regarding effective treatment. Recently, medicinal cannabis has proven to be effective in chronic pain conditions such as osteoarthritis, neuropathic pain, and other non-cancer chronic pain. However, further research is needed about how the cannabinoid system works with the pain pathway. Using the fact that medicinal cannabis is effective in the treatment of chronic pain and certain rheumatic diseases, in this review, we aim to analyze the role of the cannabinoid system in fibromyalgia syndrome.

We followed Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines in searching PubMed, MEDLINE (through PubMed), PubMed Central, and Google Scholar using keywords "fibromyalgia, chronic pain, cannabis, cannabinoids, pharmacotherapy, alternative therapy" and Medical Subject Heading (MeSH) words.

After applying inclusion/exclusion criteria and checking for the quality assessment, 22 articles were retrieved and used for the analysis of the role of cannabis in the treatment of fibromyalgia. The two main compounds of cannabis with analgesic and anti-inflammatory properties are cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC), and their ratio determines the effect on various symptoms of FMS. We included studies regarding the use of cannabinoids in the treatment of fibromyalgia, investigating the use of nabilone, dronabinol (a synthetic analog of THC), Bedrocan (22.4 mg THC, <1 mg CBD), Bediol (13.4 mg THC, 17.8 mg CBD), and Bedrolite (18.4 mg CBD, <1 mg THC).

In the era of the coronavirus disease 2019 (COVID-19) pandemic and opioid crisis, many adverse outcomes are observed in the patients suffering from FMS due to lack of any definitive treatment and promising outcomes from the known treatment options, which led to the need for effective and safer treatment alternatives.

Although the studies reviewed in this article suggest that medical cannabis is a safe and effective treatment for fibromyalgia pain, several limitations regarding dosage, length of treatment, adverse effects, long-term follow-up, and dependence needs further investigation.

Placebo effect in pharmacological management of fibromyalgia: a meta-analysis

INTRODUCTION

The management of fibromyalgia involves a combination of pharmacological and non-pharmacological treatments.

SOURCE OF DATA

Recently published literature in PubMed, Google Scholar and Embase databases.

AREAS OF AGREEMENT

Several pharmacological and non-pharmacological strategies have been proposed for the management of fibromyalgia. However, the management of fibromyalgia remains controversial. The administration of placebo has proved to be more effective than no treatment in many clinical settings and evidence supports the 'therapeutic' effects of placebo on a wide range of symptoms.

AREAS OF CONTROVERSY

The placebo effect is believed to impact the clinical outcomes, but its actual magnitude is controversial.

GROWING POINTS

A meta-analysis comparing pharmacological management versus placebo administration for fibromyalgia was conducted.

AREAS TIMELY FOR DEVELOPING RESEARCH

Drug treatment resulted to be more effective than placebo administration for the management of fibromyalgia. Nevertheless, placebo showed a beneficial effect in patients with fibromyalgia. Treatment-related adverse events occurred more frequently in the drug treatment.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of double-blind randomized clinical trials.

Proton pump inhibitors long term use-trends and patterns over 15 years of a large health maintenance organization

BACKGROUND

Proton pump inhibitors (PPI) are used for a variety of indications. Despite reported associations with undesirable effects, their long-term use is on the rise, while appropriate indications, dose, and treatment duration may deviate from guideline recommendations.

OBJECTIVES

Primary to examine the annual patterns of PPI use. Secondary- to assess indications for initiating PPI treatment, long-term use, and factors associated with long-term use in a large Israeli health maintenance organization.

METHODS

A historical cohort study of 528 420 eligible PPI users during 2000-2015, analyzed PPI use using defined daily doses and the proportion of patients covered method. Data on indications for treatment initiation, clinical and socio-demographic parameters were captured as well. A multivariable logistic-regression model was used to identify factors associated with long-term use of PPI.

RESULTS

The annual incidence rates of patients initiating PPI treatment were relatively constant, ranging between 2.4% and 3.1% of the adult population, with a monotonic increase in annual consumption and prevalence (reaching 12.7% in 2015). Reflux, functional symptoms, and Helicobacter pylori eradication were the most common indications for initiating PPI therapy. However, 27% of patients had no recorded indication for treatment. Fifteen percent of patients used PPI for over 6 months, especially in older age groups.

CONCLUSIONS

Utilization of PPI increases steadily, mainly due to chronic use. Prolonged consumption is associated with specific clinical indications and older age. Health organizations should encourage awareness of appropriate use among physicians, specifically in the elderly, patients with reflux, and those with functional disorders.

Psychoeducation for Patients with Fibromyalgia: A Systematic Review

This systematic review presents a brief and comprehensive summary of psychoeducational programs that have been designed for and tested in patients with fibromyalgia, with a focus on the features of the interventions and their main results regarding the patients’ clinical outcome. A bibliographical search performed in PubMed, Web of Science, Scopus, Cochrane Library and PsycInfo targeted publications, related to the terms “fibromyalgia” and “psychoeducation.” Information regarding the studies’ designs, age criterion, sample size, sex distribution and mean age of participants, and assessment time points, was recorded. If applicable, group distributions along with the main results regarding the patients’ clinical outcome, and features of the psychoeducational interventions were registered. Initial search eliciting 77 citations reduced to 10 relevant papers. Most of the reports come from two research projects from Spain (n = 6), worked with adult samples (n = 9), and most participants were females (88%–98%). Interventions reported significant improvements in the patients’ clinical outcomes in measures of pain intensity, fatigue, sleep quality, depression, anxiety, functional ability cognitive impairment, and quality of life. Results show not only that psychoeducational programs for the treatment of fibromyalgia are feasible, but also that they can be effective for managing physical and emotional symptoms, in particular, pain and depression.

The Association of Current Tobacco Status With Pain and Symptom Severity in Fibromyalgia Patients

Objective

To describe current tobacco use among patients with newly confirmed fibromyalgia and evaluate the association between tobacco use status and severity of reported pain and other fibromyalgia symptoms.

Patients and Methods

Participants in this study were adult patients (N=1068) with fibromyalgia who met American College of Rheumatology 2010/2011 clinical criteria for fibromyalgia at the time of initial presentation to a Midwest fibromyalgia clinic (June 1, 2018, through May 31, 2019). Multiple linear regression analyses were performed to assess the association of tobacco use status with the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS) scores. Covariates included in these analyses included age, sex, body mass index, depression, opioid medication use, and use of fibromyalgia-specific pharmacotherapy.

Results

The patients were largely women (87.0%; n=929), white (87.9%; n=939), and with an average ± SD age of 46.6±13.9 years. The WPI and SSS scores were significantly greater in current tobacco users compared with never tobacco users (WPI effect estimate [EE] = 1.03; 95% CI, 0.30 to 1.76; type III P=.020; SSS EE = 0.47; 95% CI, 0.11 to 0.84; type III P=.036). The WPI score was negatively associated with age (EE = −0.02 per year; 95% CI, −0.03 to −0.001 per year; P=.037) and no use of opioid medication (EE = −1.08; 95% CI, −1.59 to −0.57; P<.001) while positively associated with higher body mass index (EE = 0.03 per 1 kg/m²; 95% CI, 0.001 to 0.06 per kg/m²; P=.04) and higher Patient Health Questionnaire-9 score (EE = 0.12; 95% CI, 0.08 to 0.16; P<.001).

Conclusion

The results of our study suggest that tobacco use is associated with greater pain and other symptom severity in patients with fibromyalgia. These findings have important clinical and research implications for patients with fibromyalgia who use tobacco and who may benefit from early identification and timely implementation of tobacco cessation treatment to decrease pain and improve overall quality of life.

Prevalence and Clinical Significance of Metabolic Syndrome in Fibromyalgia Patients

Background and Objective Fibromyalgia syndrome (FMS) is a distressing clinical condition. Metabolic syndrome (MetS) is a biochemical and clinical condition characterised by visceral obesity, dyslipidaemia, hyperglycaemia and hypertension. The relation between the two conditions is rarely discussed. This study aimed to determine the prevalence of MetS in FMS patients and to uncover its association with the clinical severity of FMS.

Patients and Methods This cross-sectional study included 200 patients with newly diagnosed FMS. The diagnosis of FMS was established on the basis of the American College of Rheumatology (ACR) 2016 revised criteria. Patients were assessed using the validated Arabic version of Fibromyalgia Impact Questionnaire (FIQ). FMS severity was categorised according to FIQ scores into mild (≤45), moderate (>46 and≤65), and severe (>65).

Results The study included 200 FMS patients. They comprised 180 females (90.0%) and 20 males (10.0%). Among the studied patients, there were 96 patients (48.0%) who fulfilled the criteria of MetS diagnosis. A comparison between FMS patients with MetS and patients without MetS revealed a significantly higher Widespread Pain Index (WPI) [median (IQR): 12.0 (10.0–17.0) vs. 9.0 (6.0–11.0), p<0.001], a higher Symptoms Severity Scale (SSS) (10.5±1.04 vs. 8.1±1.8, p<0.001) and a higher FIQ (58.8±20.7 vs. 45.4±16.6) in patients with MetS. Patients with MetS had a significantly higher frequency of severe FMS (31.2 vs. 10.6%, p<0.001). Using binary logistic regression analysis, significant predictors of severe FMS included WPI, SSS and MetS in a univariate analysis. However, in a multivariate analysis, only WPI and SSS remained significant.

ConclusionsThis study found that MetS is prevalent in FMS patients and it may be associated with more severe forms of the disease.

Cationic liposome-encapsulated carotenoids as a potential treatment for fibromyalgia in an animal model

The present study investigated the efficacy of cationic liposome-encapsulated carotenoids (lutein or beta-carotene) as a treatment in an animal model of fibromyalgia (FM). Preparation and characterization of the nano-sized cationic liposomal carotenoids have been carried out. FM has been induced in the experimental animals via successive subcutaneous reserpine injection (1 mg/kg). Animals were divided into four groups; control, reserpinized (Res), reserpinized and cationic liposomal lutein-treated (Res + CL-Lut), and reserpinized and liposomal beta-carotene-treated (Res + CL-Bc). Levels of norepinephrine (NE), dopamine (DA), and serotonin (5-HT), and oxidative stress markers (MDA, H₂O₂, NO, and GSH) were determined in the brain's cortical tissue of the different groups of animals. Furthermore, the spectral analysis of the electrocorticogram (ECoG) was carried out. Animal behavior was tested for different animal groups. Results showed a significant reduction in monoamines, an elevation of oxidative stress markers, a shift in the ECoG frequency band power, and a change in pain threshold of the reserpinized animals. A return to a non-significant difference from the control values of all the measured parameters has been obtained after two weeks of cationic liposomal carotenoid preparations treatment. The present findings shed more light on the validity of the reserpine model of FM and provide evidence for the antidepressant, antioxidant, and anti-nociceptive potential of the cationic liposomal carotenoids. The present results proofed that the natural product preparations on a nano-sized scale could be a good alternative to the pharmacological interventions for FM treatment.

Efficacy of cannabinoids in fibromyalgia: a literature review

Fibromyalgia is a chronic disease of unclear etiology, involving a neural oversensitization and impaired pain modulation, in addition to a clinical deficiency of the endocannabinoid system. Fibromyalgia is associated with a number of somatic and psychological disorders and hence multiple pharmacological approaches have been used, including   opioids, antidepressants, antiepileptics, and more recently medical cannabis. This narrative review comprises a review of the current literature on the efficacy of   cannabinoids in fibromyalgia. The studies describe a possible influence of cannabis on pain control in patients with fibromyalgia, with positive effects on quality of life and sleep. The use of cannabis seems to be beneficial in patients with fibromyalgia; however, more robust studies are still needed to establish is actual efficacy in pain management, quality of life and improvement of associated symptoms.

The Pharmacology and Clinical Efficacy of Antiseizure Medications: From Bromide Salts to Cenobamate and Beyond

Epilepsy is one of the most common and disabling chronic neurological disorders. Antiseizure medications (ASMs), previously referred to as anticonvulsant or antiepileptic drugs, are the mainstay of symptomatic epilepsy treatment. Epilepsy is a multifaceted complex disease and so is its treatment. Currently, about 30 ASMs are available for epilepsy therapy. Furthermore, several ASMs are approved therapies in nonepileptic conditions, including neuropathic pain, migraine, bipolar disorder, and generalized anxiety disorder. Because of this wide spectrum of therapeutic activity, ASMs are among the most often prescribed centrally active agents. Most ASMs act by modulation of voltage-gated ion channels; by enhancement of gamma aminobutyric acid-mediated inhibition; through interactions with elements of the synaptic release machinery; by blockade of ionotropic glutamate receptors; or by combinations of these mechanisms. Because of differences in their mechanisms of action, most ASMs do not suppress all types of seizures, so appropriate treatment choices are important. The goal of epilepsy therapy is the complete elimination of seizures; however, this is not achievable in about one-third of patients. Both in vivo and in vitro models of seizures and epilepsy are used to discover ASMs that are more effective in patients with continued drug-resistant seizures. Furthermore, therapies that are specific to epilepsy etiology are being developed. Currently, ~ 30 new compounds with diverse antiseizure mechanisms are in the preclinical or clinical drug development pipeline. Moreover, therapies with potential antiepileptogenic or disease-modifying effects are in preclinical and clinical development. Overall, the world of epilepsy therapy development is changing and evolving in many exciting and important ways. However, while new epilepsy therapies are developed, knowledge of the pharmacokinetics, antiseizure efficacy and spectrum, and adverse effect profiles of currently used ASMs is an essential component of treating epilepsy successfully and maintaining a high quality of life for every patient, particularly those receiving polypharmacy for drug-resistant seizures.