2016 EULAR FMS Guidelines

EXTENDED REPORT
EULAR revised recommendations for the
management of fibromyalgia
G J Macfarlane,1
C Kronisch,1,2
L E Dean,1
F Atzeni,3
W Häuser,4,5
E Fluß,1
E Choy,6
E Kosek,7
K Amris,8
J Branco,9
F Dincer,10
P Leino-Arjas,11
K Longley,12
G M McCarthy,13
S Makri,14
S Perrot,15
P Sarzi-Puttini,16
A Taylor,17
G T Jones1
Handling editor Tore K Kvien
▸ Additional material is
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For numbered affiliations see
end of article.
Correspondence to
Professor G J Macfarlane,
Epidemiology Group, University
of Aberdeen, School of
Medicine, Medical Sciences
and Nutrition, Polwarth
Building, Foresterhill,
Aberdeen, Scotland AB25 2ZD,
UK; g.j.macfarlane@abdn.ac.uk
Received 15 April 2016
Revised 10 June 2016
Accepted 14 June 2016
To cite: Macfarlane GJ,
Kronisch C, Dean LE, et al.
Ann Rheum Dis Published
Online First: [please include
Day Month Year]
doi:10.1136/annrheumdis-
2016-209724
ABSTRACT
Objective The original European League Against
Rheumatism recommendations for managing
fibromyalgia assessed evidence up to 2005. The paucity
of studies meant that most recommendations were
‘expert opinion’.
Methods A multidisciplinary group from 12 countries
assessed evidence with a focus on systematic reviews
and meta-analyses concerned with pharmacological/non-
pharmacological management for fibromyalgia. A review,
in May 2015, identified eligible publications and key
outcomes assessed were pain, fatigue, sleep and daily
functioning. The Grading of Recommendations
Assessment, Development and Evaluation system was
used for making recommendations.
Results 2979 titles were identified: from these 275 full
papers were selected for review and 107 reviews (and/or
meta-analyses) evaluated as eligible. Based on meta-
analyses, the only ‘strong for’ therapy-based
recommendation in the guidelines was exercise. Based
on expert opinion, a graduated approach, the following
four main stages are suggested underpinned by shared
decision-making with patients. Initial management
should involve patient education and focus on non-
pharmacological therapies. In case of non-response,
further therapies (all of which were evaluated as ‘weak
for’ based on meta-analyses) should be tailored to the
specific needs of the individual and may involve
psychological therapies (for mood disorders and
unhelpful coping strategies), pharmacotherapy (for severe
pain or sleep disturbance) and/or a multimodal
rehabilitation programme (for severe disability).
Conclusions These recommendations are underpinned
by high-quality reviews and meta-analyses. The size of
effect for most treatments is relatively modest. We
propose research priorities clarifying who will benefit
from specific interventions, their effect in combination
and organisation of healthcare systems to optimise
outcome.
INTRODUCTION
Fibromyalgia is common with a prevalence of 2%
in the general population.1 2
However, its diagnosis
and management remain a challenge for patients
and healthcare professionals. It often takes >2 years
for a diagnosis to be made with an average of 3.7
consultations with different physicians.3
Referral to
specialists and investigations results in high health-
care use, for up to 10 years prior to diagnosis, com-
pared with persons who do not have fibromyalgia.4
Although pain is the dominant symptom in fibro-
myalgia, other symptoms such as fatigue, non-
refreshed sleep, mood disturbance and cognitive
impairment are common, but not universal, have an
important influence on quality of life and emphasise
that it is a heterogeneous and complex condition.5 6
The original European League Against Rheumatism
(EULAR) recommendations for the management
of fibromyalgia assessed evidence up to and in-
cluding 2005.7
Given the paucity of information
and poor quality of the studies available, it was
recommended that the guidelines be revised after a
period of 4 years. However, no subsequent revision
took place and thus a decade later we revisit the
recommendations with the aim of making them
more evidence based. In the time since the original
recommendations, there have been a considerable
number of individual trials examining pharmaco-
logical and non-pharmacological interventions and,
moreover, there have been systematic reviews con-
ducted for nearly all of the commonly used man-
agement strategies. Our aim therefore was, using
the systematic reviews conducted and taking into
account their quality, to make evidence-based recom-
mendations for the use of individual pharmacological
and non-pharmacological approaches, and how these
could be combined. Further, we aimed to identify
priority areas for future research.
METHODS
Working group membership
The working group included 18 members from 12
European countries: clinicians (representing rheuma-
tology, internal medicine, pain medicine and epidemi-
ology), non-clinical scientists (occupational health,
epidemiology), patient representatives and the allied
health professions (nursing).
Eligibility, search strategy and quality
assessment
We focused on systematic reviews (with or without
meta-analysis) concerned with the management of
fibromyalgia. Details of eligibility, review and quality
assessment are provided in online supplementary
text.
Evaluating evidence
We retained pain as one of the key outcomes of in-
terest, from the original guidelines, but also in-
cluded fatigue, sleep and daily functioning. The
committee considered the following in making a
Macfarlane GJ, et al. Ann Rheum Dis 2016;0:1–11. doi:10.1136/annrheumdis-2016-209724 1
Clinical and epidemiological research
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recommendation: number of trials, number of patients, out-
comes assessed, quality of reviews and the trials included within
the reviews, effect size (and 95% CI), adverse events and cost. We
used the Grading of Recommendations Assessment, Development
and Evaluation system for making recommendations.10
This is a
four-point scale: strong for/weak for/weak against/strong against;
or allowing a recommendation ‘use only for research’. The
strength of recommendation is based on the balance between
desirable and undesirable effects (considering values and prefer-
ences), confidence in the magnitude of effects and resource use.
A strong recommendation implies that, if presented with the
evidence, all or almost all informed persons would make the
recommendation for or against the therapy, while a weak recom-
mendation would imply that most people would, although a
substantial minority would not.11
Two subgroups considered the evidence for pharmacological
and non-pharmacological therapies and proposed a recommen-
dation. At a face-to-face meeting, after presentation of the evi-
dence and the preliminary recommendation, discussion resulted
in a ‘final recommendation’. In addition to the evidence on effi-
cacy/effectiveness, the committee also took into account safety.
All participants then voted on their level of agreement with the
recommendation on a scale from 0, ‘completely disagree’, to 10,
‘completely agree’. The percentage of the committee scoring at
least 7 was taken to indicate level of agreement.
RESULTS
In total, 2979 titles were identified. From these, 571 abstracts
and then 275 full papers were selected for review, and 107
reviews evaluated as eligible for consideration in making recom-
mendations for management (figure 1).
Information on the reviews informing these recommendations
on pharmacological therapy and on non-pharmacological and
complementary and alternative medicines/therapies is collated
in online supplementary tables A and B, respectively, while in-
formation from one review, for each medicine/therapy, selected
based on recency and quality is provided in tables 1 and 2,
respectively.
Evaluation of pharmacological medicines
Amitriptyline
Five reviews included up to 13 trials and a maximum of 919
subjects. Häuser et al12
reported that patients receiving amitrip-
tyline were more likely to achieve 30% pain reduction (risk
ratio (RR) 1.60, 95% CI 1.15 to 2.24), equivalent to a ‘number
needed to treat’ (NNT) of 3.54, 95% CI 2.74 to 5.01. There
was a moderate effect on sleep (standardised mean difference
(SMD) −0.56, 95% CI −0.78, to −0.34)i
and small effect on
fatigue (−0.44; −0.71 to −0.16). There was no difference in dis-
continuation rates compared with patients receiving placebo.
Nishishinya et al13
in their high-quality review concluded that
25 mg/day improved pain, sleep and fatigue at 6–8 weeks of
treatment but not at 12 weeks while 50 mg/day did not demon-
strate efficacy. Amitriptyline evaluation: weak for, at low dose
(100% agreement).
Anticonvulsants
Nine reviews of pregabalin included up to seven studies and a
maximum of 3344 patients. A recent Cochrane review24
reported patients receiving active treatment were more likely to
have 30% pain reduction, RR 1.37, 95% CI 1.22 to 1.53, with
a ‘number needed to benefit’ (NNTB) over placebo of 9, 95%
CI 7 to 13. There was a very small effect on fatigue (−0.17;
−0.25 to −0.09) and small effect on sleep (−0.35; −0.43 to
−0.27) but no effect on disability (−0.01; −0.11 to 0.09).
A single, moderate quality, study of gabapentin in 150 subjects
(eg, in ref. 104) showed a significant effect on 30% pain reduc-
tion (RR 1.65, 95% CI 1.10 to 2.48), a small effect on sleep
(−0.71; −1.08 to −0.24) and a large effect on disability (−0.94;
−1.32 to −0.56). Anticonvulsant evaluation: pregabalin—weak
for (94% agreement); gabapentin—research only (100%
agreement).
Cyclobenzaprine
A single systematic review of five studies involving 312 patients
reported that of those taking cyclobenzaprine 85% experienced
side effects and only 71% completed the studies. They were
more likely to report themselves as ‘improved’ (NNT 4.8, 95%
CI 3.0 to 11.0). Only two studies reported an ‘intention-
to-treat’ (ITT) analysis. Sleep, but not pain, showed a significant,
very small, improvement relative to baseline at the longest outcome
considered (12 weeks: SMD 0.34) and patients on placebo showed
similar improvement (SMD 0.52).25
Cyclobenzaprine evaluation:
weak for (75% agreement).
Growth hormone
A single systematic review of two studies involving 74 patients
reported an effect size on pain of 1.36 (0.01 to 1.34).16
The
improvement in functional deficit was not statistically significant
(1.24; −0.36 to 2.84). There are concerns on safety (sleep
apnoea, carpal tunnel syndrome). The drug is not approved for
fibromyalgia (FM) or related disorders in Europe. Growth
hormone evaluation: strong against (94% agreement).
Monoamine oxidase inhibitors
Four reviews identified up to three studies and 241 patients.
Häuser et al26
reported a moderate effect on pain across the
studies (−0.54; −1.02, to −0.07), but the single studies that
evaluated fatigue and sleep showed no effect. There were no dif-
ferences in dropouts or adverse events compared with placebo.
There was no comparison between compounds. Life-threatening
interactions have been documented. Monoamine oxidase inhibi-
tors (MAOIs) evaluation: weak against (81% agreement).
NSAIDs
A single review21
identified two small trials with no evidence
of improved outcome compared with placebo. One low-quality
review was not considered. Non-steroidal anti-inflammatory
drugs (NSAIDs) evaluation: weak against (100% agreement).
Serotonin-noradrenalin reuptake inhibitors
Eight systematic reviews were identified, which presented data
separately for duloxetine. The largest review of 2249 subjects32
reported duloxetine, short term (up to 12 weeks) and long term
(up to 28 weeks), was more effective than placebo at reducing
pain (RR >30% pain, RR 1.38, 95% CI 1.22 to 1.56), although
there was no significant effect at 20–30 mg/day and no differ-
ence between doses of 60 and 120 mg/day. NNTB, based on
60 mg/day up to 12 weeks, was 6, 95% CI 3 to 12. A previous
review reported small effects on sleep (−0.24; −0.37, to −0.12)
and disability (−0.33; −0.43, to −0.24) but no effect on
fatigue.30
Seven systematic reviews were identified of milnaci-
pran, a recent one of which evaluated five trials.30
Patients
taking milnacipran were more likely, at the end of treatment, to
i
All effect sizes are expressed as SMD with 95% CI unless otherwise
stated.
2 Macfarlane GJ, et al. Ann Rheum Dis 2016;0:1–11. doi:10.1136/annrheumdis-2016-209724

have 30% pain reduction (RR 1.38, 95% CI 1.25 to 1.51) but
there was only a small benefit on fatigue (−0.14; −0.19 to
−0.08), disability (−0.16; −0.23 to −0.10) and no effect on
sleep. Duloxetine and milnacipran evaluation: weak for (100%
agreement).
Selective serotonin reuptake inhibitors
Seven systematic reviews included up to 11 trials and a
maximum of 521 subjects. Given that reviews have not focused
on specific drugs or comparisons, drugs within this class were
considered together. A recent review of medium quality included
seven trials and reported a moderate effect on pain (−0.40;
−0.73, to −0.07), sleep (−0.31; −0.60 to −0.02) and no effect
on fatigue (−0.17; −0.46 to 0.11).36
Selective serotonin reuptake
inhibitor (SSRI) evaluation: weak against (94% agreement).
Sodium oxybate
A single systematic review of five studies including 1535 patients
reported small effects sizes on pain (0.44; 0.31 to 0.58), sleep
problems (0.47; 0.28 to 0.66) and fatigue (0.48; 0.35 to 0.60).
The European Medicines Agency and the US Food and Drug
Administration refused the approval for FM because of safety
concerns.16
The drug is only approved for narcolepsy. Sodium
oxybate evaluation: strong against (94% agreement).
Figure 1 Flow chart identifying
eligible reviews.

Tramadol, a weak opioid with mild serotonin-noradrenalin
reuptake inhibitor (SNRI) activity was considered by two
reviews. Roskell et al22
identified a single study of tramadol
with paracetamol. Those in the active arm were more
likely to have 30% improvement in pain (RR 1.77, 95% CI
1.26 to 2.48). Tramadol evaluation: weak for (100%
agreement).
The literature search did not identify any reviews on corticos-
teroids, strong opioids, cannabinoids and antipsychotics. The
committee made a ‘strong against’ evaluation (100% agreement)
regarding the use of strong opioids and corticosteroids in
patients with fibromyalgia on the basis of lack of evidence of
efficacy and high risk of side effects/addiction reported in indi-
vidual trials.
Evaluation of non-pharmacological therapies;
complementary and alternative medicines and therapies
Acupuncture
Eight reviews included up to 16 trials and 1081 participants.
One high-quality review included nine trials, with 395 patients,
and demonstrated that acupuncture, added to standard therapy,
resulted in a 30% (21%, 39%) improvement in pain.70
Electric
acupuncture was also associated with improvements in pain
(22%; 4% to 41%) and fatigue (11%; 2% to 20%). Some
adverse events were reported, but these were commonly mild
and transient. There is little understanding of the active compo-
nent of acupuncture, and the evidence supporting the use of
real versus sham acupuncture was less consistent. Acupuncture
evaluation: weak for (93% agreement).
Table 1 Overview of results from selected systematic reviews of placebo-controlled pharmacological trials
Treatment
(review reference)
No. of trials
(no. of
participants)
Review quality Dosages; durations of treatment
Overall trial
quality* Safety and comments
Amitriptyline12
10 (767)
AMSTAR=6
10–50 mg/day; 8–24 weeks Low There was no analysis of safety but no difference in
discontinuation rates compared with patients on placebo
was reported.
Anticonvulsants—
pregabalin24
5 (3256)
AMSTAR=10
Three studies with fixed doses of 300, 450 and
600 mg/day; one with fixed doses of 150, 300 or
450 mg/day; one flexible dosing study of 300 or
450 mg/day; 8–14 weeks
High Increased likelihood of withdrawal due to adverse
events, RR 1.68, 95% CI 1.36 to 2.07; NNH 12 95% CI
9 to 17. No difference in likelihood of serious adverse
events.
Cyclobenzaprine25
5 (312)
AMSTAR=7
10–40 mg; 2–24 weeks Moderate There was no analysis of adverse outcomes in the trials
reviewed although dropout across trials was large
(cyclobenzaprine 29%, placebo 43%). Only two studies
conducted ITT.
Growth hormone16
2 (74)
AMSTAR=5
0.0125 mg/kg/day; adjusted to maintain IGF-1 level
of 250 ng/mL after first month, 0.0125 mg/kg/day;
9 months to 1 year
NE Safety concerns include sleep apnoea and carpal tunnel
syndrome.
MAOIs26
3 (241)
AMSTAR=9
Pirlindole 150 mg/day, moclobemide 150–300 mg/
day; 4–12 weeks
Low MAOIs are known to cause potentially fatal hypertensive
crises, serotonin syndrome and psychosis when they
interact with foods containing tyramine and medications
(many of which are commonly used in the treatment of
FM), including SSRIs, tricyclic antidepressants and
tramadol. The clinical trials had restrictions on
concomitant medications.
NSAIDs21
2 (242)
AMSTAR=7
Ibuprofen 600 mg four times a day, tenoxicam
20 mg/day; 6–8 weeks
Low The adverse event profile, although not considered in
this review, is well established for this class of drugs.
SNRIs—duloxetine31
6 (2249)
AMSTAR=10
20–120 mg/day; 12–28 weeks Moderate Dropout rates due to side effects across studies higher
than with placebo. No difference in serious adverse
events.
SNRIs—
milnacipran30
5 (4118)
AMSTAR=10
100 or 200 mg/day; 12–27 weeks High Dropout rates due to side effects across studies were
double compared with placebo, but there was no
difference in serious adverse events.
SSRIs36
7 (322)
AMSTAR=8
20–40 mg/day citalopram, 20–80 mg/day fluoxetine,
20–60 mg/day paroxetine; 6–16 weeks
Moderate to
high
Acceptability and tolerability were similar to placebo
NNH 40, 95% CI 19 to 66. Although several studies
excluded patients with depression/anxiety, Häuser et al26
showed a small effect of SSRIs in improving depressed
mood (SMD −0.37, 95% CI −0.66 to −0.07).
Sodium oxybate16
5 (1535)
AMSTAR=5
4.5–6 g/day; 8–14 weeks NE There is the potential for abuse and central nervous
system effects associated with abuse such as seizure,
respiratory depression and decreased levels of
consciousness.
Tramadol22
1 (313)
AMSTAR=3
37.5 mg tramadol/325 mg paracetamol 4×/day;
3 months
High No significant difference in discontinuation due to
adverse events (RR 1.62, 95% CI 0.94 to 2.80). A
high-quality review (AMSTAR score 7) identified a single
study, which, among persons who tolerated and
benefitted from tramadol, demonstrated a lower
discontinuation rate in a double-blind phase compared
with placebo.21
*According to the method of quality evaluation used in the review.
AMSTAR, Assessing the Methodological Quality of Systematic Reviews; FM, fibromyalgia; IGF, insulin growth factor; ITT, intention-to-treat; MAOIs, monoamine oxidase inhibitors; NE, not
evaluated; NNH, number needed to harm; NSAIDs, non-steroidal anti-inflammatory drugs; RR, risk ratio; SMD, standardised mean difference; SNRI, serotonin-noradrenalin reuptake
inhibitor; SSRI, selective serotonin reuptake inhibitor.

Table 2 Overview of results from selected systematic reviews of non-pharmacological; complementary and alternative medicine and therapy trials
Treatment
(review reference)
No. of trials
(no. of participants*)
Review quality Dosages; durations of treatment
Overall trial
quality† Safety and comments
Acupuncture70
9 (395)
AMSTAR=11
Treatment sessions ranged from 3 to 13 weeks (median=4), with needle retention
ranging from 20 to 30 min. Only one study provided journal references for the
acupuncture point selection, and the description of the type of needle stimulation/
manipulation was clear in only three studies.
Moderate One in six people who had acupuncture, and one in three controls, reported adverse
events. Such events were minor and lasted less than one day. No serious adverse events
were reported in any trials.
Biofeedback92
7 (321)
AMSTAR=8
EMG biofeedback.
Individual sessions varied between 45 and 180 min, and the number of sessions varied
between 6 and 16.
EEG biofeedback.
20–22 sessions of (where reported) 30 min duration.
Poor Only two‡ trials reported adverse event data. 4% of patients in one trial receiving EMG
biofeedback reported stress. And 74% of patients in another, receiving EEG biofeedback
reported a variety of side effects, including: headache, fatigue and sleep problems.
Capsaicin94
2 (153)
AMSTAR=5
Topical application of Capsicum annuum L. cream, either
0.025% capsaicin for 4 weeks or 0.075% for 12 weeks.
Not reported Patients reported moderate, transient, burning or stinging.
Chiropractic89
3 (102)
AMSTAR=4
Little detail is given for any trials, but treatment elements included massage, stretching,
spinal manipulation, education and resistance training.
Low Around 50% of patients experience mild-to-moderate transient adverse effects after
spinal manipulation.§
CBT57
23 (2031)
AMSTAR=11
Median duration of therapy=10 weeks, with a median number of 10 sessions, and
median total hours=18 hours. All but two studies delivered therapy face to face. Median
follow-up (where this was performed 17/23 studies)=6 months.
Low The assessment of safety in most studies was insufficient.
Two studies reported dropout due to worsening of comorbid mental disorders. However,
CBT is generally considered safe.
Exercise41
34 (2276)
AMSTAR=9
Exercise programmes lasting 2.5–24 weeks. Aerobic exercise for ≥20 min, once a day (or
twice for ≥10 min), 2–3 days a week. Strength training with ≥8 repetitions per exercise,
2–3 times a week.
Moderate Although patients may initially notice a deterioration in symptoms, exercise is generally
considered safe, especially when practised under supervision.
Hydrotherapy/spa
therapy76
10 (446)
AMSTAR=9
Wide variation in precise treatment strategy between trials. Most consisted of water or
mud baths at body temperature 36–37°C, or slightly above (40–45°C), with a median
treatment time of 240 min (range 200–300), over several weeks.
Low Three studies reported no side effects of treatment; one reported slight flashes in 10% of
the patients. The remaining trials did not explicitly mention safety.
Hypnotherapy91
4 (152)
AMSTAR=11
Some variation between trials ranging (where reported) from 300 to 420 min, delivered
over 10–26 weeks.
Good Adverse events were not reported in any of the trials.
Massage63
9 (404)
AMSTAR=7
Massage therapy time lasted 25–90 min, with between 1 and 20 massage sessions in
total.
Low to moderate No adverse events were reported in any of the trials.
Meditative movement80
7 (362)
AMSTAR=9
Wide variation in treatments between trials, and included yoga, tai chi, qigong or body
awareness therapy. Median (range) duration of treatment=16 (6–24) hours, over
4–12 weeks.
Moderate Although no serious adverse events were reported, six participants (3.1%) withdrew from
the trials because of adverse events (increase of pain; muscle inflammation; chlorine
hypersensitivity). The review authors concluded that the acceptance and safety of all
types of meditative movement therapies were high.
Mindfulness/mind–body
therapy84
6 (674)
AMSTAR=9
Some variation between trials. Single 2–3.5 hours session per week, for 8–10 weeks.
Four out of six programmes also included daily home practice (30–45 min) plus a single
all-day retreat.
Low Safety was assessed and reported in none of the trials.
Multicomponent
therapy60
9 (1119)
AMSTAR=9
Enormous variation in treatment strategies between trials. Most included different
combinations of exercise (land and/or water based); education; relaxation; and/or some
other specific therapeutic component (eg, Tai Chi; or massage).
Moderate No adverse events were reported in any of the trials.
SAMe93
1 (44)
AMSTAR=6
400 mg tablet, twice a day, for 6 weeks. Moderate Mild adverse effects such as stomach upset and dizziness were reported.
Other: guided
imagery91
1 (48)
AMSTAR=9
Audiotape-led, individual, guided imagery: 30 min daily for 6 weeks recommended.
Median of 44 exercises (range 37–136).
Good Adverse events were not reported.
Other: homeopathy98
4 (163)
AMSTAR=7
Variation between trials. Two studied individualised homeopathic treatment, consisting of
an initial consultation (and treatment), plus follow-up interviews every 4–8 weeks. Two
studied Arnica montana, Bryonia alba or Rhus toxicodendron (potency 6c) daily for
between 1 and 3 months.
Low to moderate No information was provided on safety.
*Total number of persons randomised.
†According to the method of quality evaluation used in the review.
‡Elsewhere in the review, it reports that three studies reported on adverse events. However, in the table where these data are presented, it is only clear for two. However, in a third trial, there were no dropouts due to side effects.
§These data were not contained in this review. The initial recommendation for chiropractic was weak against. However, after discussion, this was downgraded to strong against due to potential safety concerns.
CBT, cognitive behavioural therapy; EMG, electromyographic; SAMe, S-adenosyl methionine.
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Biofeedback
Two reviews included up to seven trials and 307 participants.
Glombiewski et al92
reviewed seven studies, comprising 321
participants. Treatment sessions varied from 6 to 22; with
control therapy comprising sham biofeedback, attention control,
medication and treatment as usual. Biofeedback was effective in
reducing pain intensity (Hedges’ g=0.79; 0.22 to 1.36),
although all trials were poor quality. There was no evidence of
effectiveness in terms of fatigue or sleep and subgroup analysis
suggested that any effect was limited to electromyographic
(0.86; 0.11 to 1.62) rather than electroencephalographic bio-
feedback (0.71; −0.37 to 1.8). Biofeedback evaluation: weak
against (100% agreement).
Capsaicin
Two reviews included two trials and 153 participants. The most
recent review, a narrative review of two trials, considered data
on 153 patients.94
Both showed some evidence of positive
effect in terms of pain relief, although results were not consist-
ent for other outcomes. Capsaicin gel is generally considered
safe, although many users report a mild burning sensation when
applied to the skin. However, the number of patients and trials
was small and was therefore limited in the extent to which they
can provide evidence for toxicity. Capsaicin evaluation: weak
against (86% agreement).
Chiropractic
Three reviews included up to 13 trials and 102 participants.
The most recent review summarised three studies.89
One study
was an open pilot study, one quasi-randomised and in the third
no between-group differences were observed in terms of pain.
The studies were poor quality and lacked robust interpretable
data. Chiropractic evaluation: strong against (93% agreement).
Cognitive behavioural therapies
Five reviews included up to 30 trials and at least 2031 partici-
pants. One high-quality review included 23 trials, comprising
>2000 patients, although the quality of individual trials was
reported as generally poor.58
Cognitive behavioural therapies
(CBTs) were effective in reducing pain (−0.29; −0.49 to −0.17)
and disability (−0.30; −0.51 to −0.08) at the end of treatment
compared with a variety of controls groups, and results were
sustained long term. Behavioural therapy evaluation: weak for
(100% agreement).
Exercise
Twenty reviews included up to 34 trials and at least 2494 parti-
cipants.ii
The largest, a Cochrane review, considered 47 different
exercise interventions.41
Aerobic exercise was associated with
improvements in pain (0.65; −0.09 to 1.39) and physical func-
tion (0.66; 0.41 to 0.92). Busch et al42
reviewed five trials
with 219 participants and concluded that resistance training
resulted in a significant improvement in pain (−3.3 cm on a
10 cm scale; −6.35 to −0.26) as well as function compared with
control. There is some consistency with regard to aerobic and
strengthening exercises, although insufficient evidence to suggest
superiority of one over the other; land and aquatic exercise
appear equally effective.56
Exercise therapy evaluation: strong for
(100% agreement).
Hydrotherapy/spa therapy
Four reviews included up to 21 trials and 1306 participants.
One high-quality review included 10 trials, 446 participants and
compared a median of 4-hour hydrotherapy (range 200–
300 min) against various comparators.76
There was a significant
improvement in pain (−0.78; −1.42 to −0.13) at the end of
therapy, maintained in the longer term (median 14 weeks),
although the review authors noted that no trials conducted an
ITT analysis. There was consistency with regard to the evidence
for hydrotherapy and balneotherapy, although little evidence to
suggest superiority of one over the other.77
Hydrotherapy evalu-
ation: weak for (93% agreement).
Hypnotherapy
One review included four trials, although the number of partici-
pants is unclear.91
Although six trials of hypnotherapy and/or
guided imagery were reviewed, only four examined hypnother-
apy in isolation. Median treatment duration (where reported)
was 360 min and hypnotherapy was compared with a variety of
control therapies: cognitive intervention, active control (phys-
ical therapy/massage/relaxation/autogenic training) and treat-
ment as usual. A meta-analysis is presented on all six trials, and
isolated data for hypnotherapy are not presented. Two of the
four hypnotherapy trials report some significant benefit in terms
of pain, the other two demonstrate null, non-significant results.
Hypnotherapy evaluation: weak against (86% agreement).
Massage
Six reviews have been reported and one meta-analysis with nine
trials and 404 patients63
with sessions lasting 25–90 min, and
treatment duration ranging from 1 to 24 weeks (median 5
weeks). Comparator treatments included transcutaneous elec-
trical nerve stimulation (TENS), standard care, guided relaxation
and acupuncture. Methodological problems were noted with all
of the studies, only four were at low risk of bias in terms of
random allocation and only two were analysed as ITT. Overall,
massage was not associated with a significant improvement in
pain (0.37; −0.19 to 0.93), and of the two ITT analyses, one
favoured massage and one favoured control (both significant).
A subgroup analysis revealed some evidence of a positive effect
with massage of ≥5 weeks duration, although this was based
solely on lower-quality trials. Massage evaluation: weak against
(86% agreement).
Meditative movement
Six reviews, including up to eight trials and 559 participants,
focused on qigong, yoga, tai chi or a combination of these ther-
apies. However, there was insufficient evidence to make in-
dividual recommendations. One review included seven trials,
with 362 participants randomised to tai chi, yoga, qigong or
body awareness therapy.80
Total treatment time ranged from 12
to 24 hours and was compared with a variety of controls,
including treatment as usual and active control groups (aerobics,
wellness education and stretching). At the end of therapy,
improvements were seen in sleep (−0.61; −0.95 to −0.27) and
fatigue (−0.66; −0.99 to −0.34) some of which were main-
tained in the longer term. Meditative movement evaluation:
weak for (71% agreement).
Mindfulness/mind–body therapy
Six reviews included up to 13 trials and 1209 participants. One
recent review, a meta-analysis of six trials, with 674 patients84
provided evidence that mindfulness-based stress reduction
ii
It is unclear from some of the reviews how many participants were
included. The number of participants represents the minimum about
which we can be confident.

resulted in improvements in pain (−0.23; −0.46 to −0.01)
immediately post treatment compared with usual care and com-
pared with active control interventions (−0.44; −0.73 to
−0.16). However, these effects were not robust against bias.
Mindfulness/mind–body therapy evaluation: weak for (73%
agreement).
Multicomponent therapy
Two reviews including up to 27 trials and 2407 participants exam-
ined the additional benefit of combining therapies compared with
individual therapy. Häuser et al60
conducted a review of manage-
ment involving both educational or psychological therapies and
exercise. In a meta-analysis of nine trials and 1119 patients, multi-
component therapy was effective in reducing pain (−0.37; −0.62
to −0.13), and fatigue, immediately post treatment, compared
with waiting list, relaxation, treatment as usual and education.
However, effects were short-lived. Multicomponent therapy evalu-
ation: weak for (93% agreement).
S-Adenosyl methionine
Two reviews each included one trial with, in combination, 74
participants. De Silva et al93
reported that, after the end of
treatment, significant improvements were observed in pain and
fatigue compared with placebo. Sim and Adams52
reviewed a
trial comparing S-adenosyl methionine (SAMe) with TENS but
data on the main trial comparison are omitted. Side effects are
usually mild and infrequent. However, the number of patients
and trials was small and therefore cannot provide a robust
assessment of toxicity and safety. SAMe evaluation: weak against
(93% agreement).
Other complementary and alternative therapies
Three reviews of guided imagery included up to six trials and
357 participants. The highest quality, including only one trial,
provided some evidence that guided imagery may be effective in
reducing pain (−1.52; −2.17 to −0.87).90
Two reviews of hom-
eopathy included four trials and 163 participants.97 98
Both
contained a review including only four randomised trials, each
of which showed some benefit of homeopathy, on some out-
comes. However, none of the individual trials were without
serious flaws. Other complementary and alternative therapies
(guided imagery, homeopathy): strong against (93% agreement).
Reviews were identified that examined electrothermal and photo-
therapeutic therapy;99
phytothermotherapy;100
music therapy, jour-
naling/storytelling103
and static magnet therapy,101
although each
was insufficient to allow a recommendation. Marlow et al102
examined the effectiveness of transcranial magnetic and/or direct
current stimulation. Eight trials included 244 participants,
although not all were analysed by ITT, and appropriate group
comparisons were not presented for all studies. Overall, there
was little evidence to support either therapy, and several studies
reported an unacceptably high rate of adverse events and/or dis-
continuation due to headache.
EULAR revised recommendations
In terms of overall principles, we recommend, based on unani-
mous expert opinion, that optimal management requires prompt
diagnosis and providing the patient with information (including
written material) about the condition. There should be a compre-
hensive assessment of pain, function and the psychosocial
context. Management should take the form of a graduated
approach with the aim of improving health-related quality of life.
It should focus first on non-pharmacological modalities. This is
based on availability, cost, safety issues and patient preference.
We have used the evaluation of individual therapies (above) to
make 10 specific recommendations, all based on evidence from
systematic reviews and all but one from meta-analysis. The
recommendations are given in table 3, and a flow chart of how
these therapies may be used in management is shown in figure 2.
We were unanimous in providing a ‘strong for’ recommenda-
tion for the use of exercise, particularly given its effect on pain,
physical function and well-being, availability, relatively low cost
and lack of safety concerns. The available evidence did not
allow us to distinguish between the benefits of aerobic or
strengthening. We gave ‘weak for’ recommendations in relation
to meditative movement therapies (which improved sleep,
fatigue and quality of life) or mindfulness-based stress reduction
(which improved pain and quality of life); the physical therapies
acupuncture or hydrotherapy for which there was evidence that
they improved pain/fatigue and pain/quality of life, respectively.
The effects seen in pragmatic trials of such therapies will
include specific and non-specific effects, and it is not possible to
disentangle these. There were some non-pharmacological ther-
apies we did not recommend because of lack of effectiveness
and/or low study quality: biofeedback, capsaicin, hypnotherapy,
massage, SAMe and other complementary and alternative ther-
apies. We provided a ‘strong against’ evaluation for chiropractic
based on safety concerns.
In case of lack of effect of the above therapeutic approaches,
we recommend individualised treatment according to patient
need. Psychological therapies (‘weak for’) should be considered
for those with mood disorder or unhelpful coping strategies:
CBT was effective at producing modest, long-term reductions in
pain, disability and improving mood. Pharmacological therapies
(all ‘weak for’) should be considered for those with severe pain
(duloxetine, pregabalin, tramadol) or sleep disturbance (amitrip-
tyline, cyclobenzaprine, pregabalin). Multimodal rehabilitation
(‘weak for’) programmes should be considered for those with
severe disability—in comparison to individual therapies, those
that were multimodal improved a range of short-term outcomes.
We did not recommend several pharmacological therapies
including NSAIDs, MAOIs and SSRIs because of lack of efficacy
and specifically gave a ‘strong against’ evaluation to growth
hormone, sodium oxybate, strong opioids and corticosteroids
based on lack of efficacy and high risk of side effects.
DISCUSSION
The previous EULAR recommendations provided an import-
ant milestone in the management of fibromyalgia. There were
nine recommendations, but only three were supported by
strong evidence from the scientific literature; most were based
on expert opinion. Since that time, there have been a consid-
erable number of trials published addressing issues in the
management of fibromyalgia. The availability of systematic
reviews and meta-analysis of randomised controlled trials
(RCTs) for all the most common approaches to management
allowed us to concentrate on these.
Comparison with 2007 EULAR recommendations
Despite the very large increase in the amount of trial data and
summarised in meta-analyses, there are no major changes to the
approach of managing patients with fibromyalgia, although we
provide new evidence in support for some additional non-
pharmacological therapies. In addition, all the recommendations
are now firmly evidence based. We now recommend that non-
pharmacological therapy should be first-line therapy and then if
there is a lack of effect that there should be individualised

therapy according to patient need, which may include pharma-
cological therapy.
Comparison with other recommendation
There are three recent guidelines on the management of FM
from Canada, Israel and Germany that have been compared
with respect to their recommendations.105
These guidelines
and our EULAR recommendations are in agreement on the
principles of approach to management, the need for tailored
therapy to the individual and the first-line role of non-
pharmacological therapies. There are differences between our
guidelines and previous guidelines, which can partly be
explained by us using more recently available evidence. There
are differences in the strength of recommendations relating to
pharmacological therapies: anticonvulsants and SNRIs were
strongly recommended by the Canadian and Israeli guidelines
while the German and these EULAR guidelines provide a
weak recommendation. There are also differences in relation
to individual non-pharmacological therapies across guidelines
in terms of whether they were assessed. For example, medita-
tive movement is strongly recommended by the German
guidelines, but recommended only for a minority of patients
in Israel, while these EULAR guidelines provide a ‘weak for’
recommendation.
The committee recommended that an update is conducted
after 5 years in order to determine whether for those therapies
with relatively little current evidence further trials have been
conducted and, second, whether any new therapies have
emerged for the management of fibromyalgia.
Research priorities
In the course of discussion, we identified important questions in
terms of guiding management where there was either
insufficient (or often no) evidence base to guide decisions, that
is, ‘research gaps’. We discussed their relatively priority taking
into account their potential to guide management, the likeli-
hood that such studies could be conducted and were likely to be
funded. We identified five such priority questions:
▸ Which type of exercise is most effective: strength and/or
aerobic training?
▸ Are combined pharmacological and non-pharmacological
approaches to management more effective than single-
modality management?
▸ Are there characteristics of patients with fibromyalgia that
predict response to specific therapies?
▸ How should fibromyalgia be managed when it occurs as a
comorbidity to inflammatory arthritis?
▸ What aspects of a healthcare system optimise outcome for
patients (who is best for the management of FM patients)?
Some of these questions are best answered by RCTs. Given,
however, the expense of such studies and that they can take
almost 10 years from identifying the questions to be answered to
results being obtained, alternatives including registers and obser-
vational studies should be considered. These can be complemen-
ted by qualitative studies to determine the needs of patients.
Dissemination
These recommendations will be disseminated by the inter-
national working group through national rheumatology soci-
eties. This will include scientific meetings, newsletters and
continuing education programmes. We will produce a summary
of the recommendations suitable for dissemination through
EULAR-affiliated patient groups and through national patient
societies. We will investigate assessing agreement with the
recommendations in the target population.
Table 3 Recommendations
Recommendation
Level of
evidence Grade
Strength of
recommendation
Agreement
(%)*
Overarching principles
Optimal management requires prompt diagnosis. Full understanding of fibromyalgia requires comprehensive
assessment of pain, function and psychosocial context. It should be recognised as a complex and heterogeneous
condition where there is abnormal pain processing and other secondary features. In general, the management of
FM should take the form of a graduated approach.
IV D 100
Management of fibromyalgia should aim at improving health-related quality of life balancing benefit and risk of
treatment that often requires a multidisciplinary approach with a combination of non-pharmacological and
pharmacological treatment modalities tailored according to pain intensity, function, associated features (such as
depression), fatigue, sleep disturbance and patient preferences and comorbidities; by shared decision-making with
the patient. Initial management should focus on non-pharmacological therapies.
IV D 100
Specific recommendations
Non-pharmacological management
Aerobic and strengthening exercise Ia A Strong for 100
Cognitive behavioural therapies Ia A Weak for 100
Multicomponent therapies Ia A Weak for 93
Defined physical therapies: acupuncture or hydrotherapy Ia A Weak for 93
Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction Ia A Weak for 71–73
Pharmacological management
Amitriptyline (at low dose) Ia A Weak for 100
Duloxetine or milnacipran Ia A Weak for 100
Tramadol Ib A Weak for 100
Pregabalin Ia A Weak for 94
Cyclobenzaprine Ia A Weak for 75
*Percentage of working group scoring at least 7 on 0–10 numerical rating scale assessing agreement.

SUMMARY
In summary, these revised EULAR recommendations newly incorp-
orate a decade of evidence in relation to the pharmacological and
non-pharmacological management of fibromyalgia. They allow
EULAR to move from recommendations that are predominantly
based on expert opinion to ones that are firmly based on scien-
tific evidence from high-quality reviews and meta-analyses.
Despite this evidence, however, the size of effect for many treat-
ments is relatively modest. We propose focusing on the research
priorities we outline to address issues clarifying to whom certain
interventions may best be delivered, their effect in combination,
matching patients to therapies and the organisation of health-
care systems to optimise outcome.
Author affiliations
1
Epidemiology Group, School of Medicine, Medical Sciences and Nutrition,
University of Aberdeen, Aberdeen, UK
2
Department of Rheumatology, Cantonal Hospital, Fribourg, Switzerland
3
ICRCCS Galeazzi Orthopaedic Institute, Milan, Italy
Figure 2 Management recommendations as flow chart.

4
Department of Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany
5
Department of Psychosomatic Medicine, Technische Universität München, München,
Germany
6
Section of Rheumatology, Institute of Infection and Immunity, Cardiff University
School of Medicine, Cardiff, UK
7
Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Spine
Centre, Stockholm, Sweden
8
Department of Rheumatology, Bispebjerg and Frederiksberg, The Parker Institute,
Copenhagen University Hospital, Copenhagen, Denmark
9
Rheumatology Department, CEDOC-NOVA Medical School, UNL, CHLO, Hospital
Egas Moniz, Lisbon, Portugal
10
Hacettepe University Division of Internal Medicine, Department of Physical and
Rehabilitation Medicine, Ankara, Turkey
11
Finnish Institute of Occupational Health, Helsinki, Finland
12
Patient Representative, Bristol, UK
13
Mater Misericordiae University Hospital, Dublin, Ireland
14
Patient Representative, Limassol, Cyprus
15
Centre de la Douleur, Hôpital Cochin-Hôtel Dieu, Université Paris Descartes, Paris,
France
16
Rheumatology Unit, L. Sacco University Hospital, Milan, Italy
17
Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
Twitter Follow Gary Macfarlane at @UAberdeenEpi
Contributors GJM, FA, PS-P, EC and GTJ were applicants on the grant. EF and LED
undertook the literature search and together with FA identified eligible reviews. EF, LED,
FA and CK evaluated the quality of each of the eligible reviews. GTJ led the evaluation
of non-pharmacological therapies and FA and CK led the evaluation of pharmacological
therapies. GJM drafted the manuscript with input from GTJ, WH, EC, CK and EK. All
authors (with the exception of FA and EF) participated in a 2-day project meeting, and
all authors made important intellectual contributions to the manuscript.
Funding The project was funded by EULAR.
Competing interests CK undertook work in this project supported by a fellowship
from the Swiss Society for Rheumatology. SP has received personal fees from Pierre
Fabre, Pfizer, Eli Lilly and Jazz pharmaceutical (advisory boards and research
activities). EC has received personal fees from Pfizer, Eli Lilly and Tonix (advisory
boards and speaker fees). WH has received personal fees from MSD and Grünenthal
(speaker fees), was head of the steering committee of the German guidelines on
fibromyalgia and is a member of the medical board of the German Fibromyalgia
Association. GJM has received personal fees from Pfizer (research activities). EK
reports personal fees from Lundbeck, Orion and research funding from Eli Lilly. GMM
reports personal fees from Pfizer, A Menarini, Hospiri and BMS, and has received
research funding from AbbVie and Pfizer. PS-P reports personal fees from Abbott,
Roche, Pfizer, UCB, MSD and has received research funding from Pfizer, UCB, Roche.
Provenance and peer review Not commissioned; externally peer reviewed.
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management of fibromyalgia
EULAR revised recommendations for the
M McCarthy, S Makri, S Perrot, P Sarzi-Puttini, A Taylor and G T Jones
Choy, E Kosek, K Amris, J Branco, F Dincer, P Leino-Arjas, K Longley, G
G J Macfarlane, C Kronisch, L E Dean, F Atzeni, W Häuser, E Fluß, E
published online July 4, 2016Ann Rheum Dis
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