https://doi.org/10.4081/reumatismo.2021.1362
The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of fibromyalgia. Best practices based on current scientific evidence
Submitted: 21 October 2020
Accepted: 25 May 2021
Published: 3 August 2021
Accepted: 25 May 2021
Abstract Views: 8190
PDF: 2651
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All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Fibromyalgia or fibromyalgia syndrome (FMS) is defined as a central sensitization syndrome characterized by the dysfunction of neurocircuits detecting, transmitting and processing nociceptive stimuli; the prevalent manifestation is musculoskeletal pain. In addition to pain, there are multiple accompanying symptoms, in common with other algo-dysfunctional syndromes, which are reflected in a broad spectrum of somatic, neurocognitive and neuro-vegetative manifestations. An evidence-based approach is essential in FMS management, in order to improve patient health and to reduce its social burden. Since in the last ten years new international guidelines for clinical practice (Clinical Practice Guidelines or CPGs) concerning FMS diagnosis and pharmacological/ non-pharmacological management have been published, the Italian Society of Rheumatology (SIR) has decided to adapt them to the Italian national setting. The framework of the Guidelines International Network Adaptation Working Group was adopted to identify, appraise (AGREE II), synthesize, and customize the most recent CPGs on FMS to the needs of the Italian healthcare context. A working group of rheumatologists from SIR epidemiology unit and FMS experts identified relevant clinical questions to guide the systematic review of the literature. The target audience of these CPGs included physicians and healthcare professionals who manage FMS. The adapted recommendations were finally assessed by an external multidisciplinary panel. From the systematic search in databases (Pubmed/Medline, Embase) and grey literature, 6 CPGs were selected and appraised by two independent raters. The combination of the scientific evidence underlying the original CPGs with expert opinion lead to the development of 17 recommendations. The quality of evidence for each recommendation was reported and their potential impact on clinical practice was assessed. These SIR recommendations are expected to be a valuable aid in the diagnosis and treatment of FMS, as they will contribute to disseminate the best practice on the basis of the current scientific evidence.
Siracusa R, Paola RD, Cuzzocrea S, Impellizzeri D. Fibromyalgia: pathogenesis, mechanisms, diagnosis and treatment options update. Int J Mol Sci. 2021; 22: 3891.
DOI: https://doi.org/10.3390/ijms22083891
Salaffi F, De Angelis R, Grassi W; Marche Pain Prevalence; INvestigation Group (MAPPING) study. Prevalence of musculoskeletal conditions in an Italian population sample: results of a regional community-based study. I. The MAPPING study. Clin Exp Rheumatol. 2005; 23:819-28.
Clauw DJ. Fibromyalgia. A clinical review. JAMA. 2014; 311: 1547-55.
DOI: https://doi.org/10.1001/jama.2014.3266
Jones GT, Atzeni F, Beasley M, et al. The prevalence of fibromyalgia in the general population. A comparison of the American College of Rheumatology 1990, 2010, and Modified 2010 Classification Criteria. Arthrit Rheumatol. 2015; 67 : 568-75.
DOI: https://doi.org/10.1002/art.38905
Harris RE, Clauw DJ, Scott DJ, et al. Decreased central mu-opioid receptor availability in fibromyalgia. J Neurosci. 2007; 27: 10000-6.
DOI: https://doi.org/10.1523/JNEUROSCI.2849-07.2007
Kadetoff D, Lampa J, Westman M, et al. Evidence of central inflammation in fibromyalgia-increased cerebrospinal fluid interleukin-8 levels. J Neuroimmunol. 2012; 242: 33-8.
DOI: https://doi.org/10.1016/j.jneuroim.2011.10.013
Watkins LR, Hutchinson MR, Rice KC, Maier SF. The ‘toll’ of opioid-induced glial activation: improving the clinical efficacy of opioids by targeting glia. Trends Pharmacol Sci. 2009; 30: 581-91.
DOI: https://doi.org/10.1016/j.tips.2009.08.002
Harris RE, Sundgren PC, Craig AD, et al. Elevated insular glutamate in fibromyalgia is associated with experimental pain. Arthritis Rheum. 2009; 60: 3146-52.
DOI: https://doi.org/10.1002/art.24849
Foerster BR, Petrou M, Edden RA, et al. Reduced insular gamma- aminobutyric acid in fibromyalgia. Arthritis Rheum. 2012; 64: 579-83.
DOI: https://doi.org/10.1002/art.33339
Petrovic P, Kalso E, Petersson KM, Ingvar M. Placebo and opioid analgesia-- imaging a shared neuronal network. Science. 2002; 295: 1737-40.
DOI: https://doi.org/10.1126/science.1067176
Guedj E, Taieb D, Cammilleri S, et al. 99mTc-ECD brain perfusion SPECT in hyperalgesic fibromyalgia. Eur J Nucl Med Mol Imaging. 2007; 34: 130-4.
DOI: https://doi.org/10.1007/s00259-006-0174-7
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. 2002; 46: 1333-43.
DOI: https://doi.org/10.1002/art.10225
Feraco P, Bacci A, Pedrabissi F, et al. Metabolic abnormalities in pain-processing regions of patients with fibromyalgia: a 3T MR spectroscopy study. AJNR Am J Neuroradiol. 2011; 32: 1585-90.
DOI: https://doi.org/10.3174/ajnr.A2550
Hauser W, Ablin J, Fitzcharles MA, et al. Fibromyalgia. Nat Rev Dis Primers. 2015: 15022.
DOI: https://doi.org/10.1038/nrdp.2015.22
Littlejohn G. Neurogenic neuroinflammation in fibromyalgia and complex regional pain syndrome. Nat Rev Rheumatol. 2015; 11: 639-48.
DOI: https://doi.org/10.1038/nrrheum.2015.100
Uceyler N, Zeller D, Kahn AK, et al. Small fibre pathology in patients with fibromyalgia syndrome. Brain. 2013; 136: 1857-67.
DOI: https://doi.org/10.1093/brain/awt053
Goldenberg DL, Schur PH, Romain PL. Differential diagnosis of fibromyalgia. Literature review. UpToDate; 12 sept 2016.
Arnold LM, Clauw DJ, McCarberg BH. Improving the recognition and diagnosis of fibromyalgia. Concise review for clinicians. Mayo Clin Proc. 2011; 86: 457-64.
DOI: https://doi.org/10.4065/mcp.2010.0738
Fervers B, Burgers JS, Haugh MC, et al. Adaptation of clinical guidelines: literature review and proposition for a framework and procedure. Int J Qual Health Care. 2006; 18: 167-76.
DOI: https://doi.org/10.1093/intqhc/mzi108
Fervers B, Burgers JS, Voellinger R, et al; ADAPTE Collaboration. Guideline adaptation: an approach to enhance efficiency in guideline development and improve utilisation. BMJ Qual Saf. 2011; 20: 228-36.
DOI: https://doi.org/10.1136/bmjqs.2010.043257
AGREE II Users’ Manual; 2013. Available from: https://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf
Oxford Centre for Evidence-based Medicine. Levels of Evidence; March 2009. Available from: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
Manara M, Ughi N, Ariani A, et al. Providing updated guidelines for the management of rheumatic diseases in Italy with the ADAPTE methodology: a project by the Italian Society for Rheumatology. Reumatismo. 2019; 71: 1-4.
DOI: https://doi.org/10.4081/reumatismo.2019.1186
Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2016; 76: 318-28.
DOI: https://doi.org/10.1136/annrheumdis-2016-209724
Fitzcharles M-A, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Vol. 18, Pain Research & Management; 2013. pp. 119-126. doi: 10.1155/2013/918216
DOI: https://doi.org/10.1155/2013/918216
Eich W, Häuser W, Arnold B, et al; Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Das Fibromyalgiesyndrom. Allgemeine Behandlungsgrundsätze, Versorgungskoordination und Patientenschulung (Fibromyalgia syndrome. General principles and coordination of clinical care and patient education). Schmerz. 2012; 26: 268-75. [In German].
DOI: https://doi.org/10.1007/s00482-012-1167-z
Eich W, Häuser W, Arnold B, et al; Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Das Fibromyalgiesyndrom. Definition, Klassifikation, klinische Diagnose und Prognose (Fibromyalgia syndrome. Definition, classification, clinical diagnosis and prognosis). Schmerz. 2012; 26: 247-58. [In German].
DOI: https://doi.org/10.1007/s00482-012-1169-x
Häuser W, Eich W, Herrmann M, et al. Fibromyalgia syndrome: classification, diagnosis, and treatment. Dtsch Arztebl Int 2009; 106: 383-91.
DOI: https://doi.org/10.3238/arztebl.2009.0729b
Direzione Generale Cura della Persona, Salute e Welfare regionale, dell’Agenzia Sanitaria e Sociale regionale, delle Aziende Sanitarie della Emilia-Romagna. Linee di Indirizzo per la diagnosi e il trattamento della Fibromialgia; 2018. Available from: https://salute.regione.emilia-romagna.it/normativa-e-documentazione/linee-di-indirizzo/fibromialgia
Salaffi F, Farah S, Di Carlo M, et al; Italian Society of Rheumatology (SIR) and Ministero della Salute - Direzione Generale della Programmazione Sanitaria, Roma, Italy. The Italian Fibromyalgia Registry: a new way of using routine real-world data concerning patient-reported disease status in healthcare research and clinical practice. Clin Exp Rheumatol. 2020; 38 Suppl 123: 65-71.
Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016; 46: 319‐29.
DOI: https://doi.org/10.1016/j.semarthrit.2016.08.012
Salaffi F, Di Carlo M, Farah S, et al. Diagnosis of fibromyalgia: comparison of the 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status. Rheumatology (Oxford) 2020 Mar 24.
DOI: https://doi.org/10.1093/rheumatology/keaa061
Grayston R, Czanner G, Elhadd K, et al. A systematic review and meta-analysis of the prevalence of small fiber pathology in fibromyalgia: Implications for a new paradigm in fibromyalgia etiopathogenesis. Semin Arthritis Rheum. 2019; 48: 933-40.
DOI: https://doi.org/10.1016/j.semarthrit.2018.08.003
Santos J, Alarcão J, Fareleira F, et al. Tapentadol for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015; (5): CD009923.
DOI: https://doi.org/10.1002/14651858.CD009923.pub2
Littlejohn GO, Guymer EK, Ngian GS. Is there a role for opioids in the treatment of fibromyalgia? Pain Manag. 2016; 6: 347-55.
DOI: https://doi.org/10.2217/pmt-2016-0012
Derry S, Cording M, Wiffen PJ, et al. Pregabalin for pain in fibromyalgia in adults. Cochrane Database Syst Rev. 2016; 9: CD011790.
DOI: https://doi.org/10.1002/14651858.CD011790.pub2
Sarzi-Puttini P, Ablin J, Trabelsi A, et al. Cannabinoids in the treatment of rheumatic diseases: Pros and cons. Autoimmun Rev. 2019; 18: 102409.
DOI: https://doi.org/10.1016/j.autrev.2019.102409
Sarzi-Puttini P, Batticciotto A, Atzeni F, et al. Medical cannabis and cannabinoids in rheumatology: where are we now? Expert Rev Clin Immunol. 2019; 15: 1019-32.
DOI: https://doi.org/10.1080/1744666X.2019.1665997
Giorgi V, Bongiovanni S, Atzeni F, et al. Adding medical cannabis to standard analgesic treatment for fibromyalgia: a prospective observational study. Clin Exp Rheumatol. 2020; 38 Suppl 123: 53-9.
Pérez-Fernández MR, Calvo-Ayuso N, Martínez-Reglero C, et al. Efficacy of baths with mineral-medicinal water in patients with fibromyalgia: a randomized clinical trial. Int J Biometeorol. 2019; 63: 1161-70.
DOI: https://doi.org/10.1007/s00484-019-01729-7
Bazzichi L, Da Valle Y, Rossi A, et al. A multidisciplinary approach to study the effects of balneotherapy and mud-bath therapy treatments on fibromyalgia. Clin Exp Rheumatol. 2013; 31: S111-20.
Andrade A, Hech Dominski F, Mendes Sieczkowska S. What we already know about the effects of exercise in patients with fibromyalgia: An umbrella review. Semin Arthrit Rheum. 2020; 50: 1465-80.
DOI: https://doi.org/10.1016/j.semarthrit.2020.02.003
Salaffi F, Bazzichi L, Atzeni F, et al. Characterization and definition of disease severity status in fibromyalgia: results from a cross-sectional survey of 2,339 Italian people. Rheumatology (Oxford) 2021; 60: 728-36.
DOI: https://doi.org/10.1093/rheumatology/keaa355
Sarzi-Puttini P, Batticciotto A, Atzeni F, et al. Medical cannabis and cannabinoids in rheumatology: where are we now? Expert Rev Clin Immunol. 2019;15: 1019-32.
DOI: https://doi.org/10.1080/1744666X.2019.1665997
How to Cite
Ariani, A., Bazzichi, L., Sarzi-Puttini, P., Salaffi, F., Manara, M., Prevete, I., Bortoluzzi, A., Carrara, G., Scirè, C., Ughi, N., & Parisi, S. (2021). The Italian Society for Rheumatology clinical practice guidelines for the diagnosis and management of fibromyalgia. Best practices based on current scientific evidence. Reumatismo, 73(2), 89–105. https://doi.org/10.4081/reumatismo.2021.1362
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