Do Patients Diagnosed with Fibromyalgia Receive Guideline-compliant Treatment?

Although established guidelines for treating fibromyalgia recommend the use of antiepileptics (AEDs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and tramadol, many patients and their clinicians are not satisfied with initial treatment, and often switch to one or more different medications, including nontramadol opioids, which are not recommended for treating this condition.

At the 2014 annual clinical meeting of the American Academy of Pain Management, in Phoenix, AZ, Elizabeth T. Masters, MS, MPH, and colleagues presented results from a large retrospective study that evaluated initial therapy and treatment patterns of medication used by newly diagnosed fibromyalgia patients and the level of adherence to guidelines.

The authors looked at medical and pharmacy claims data and enrollment information for adult commercial health plan members of a large US health plan. They identified newly diagnosed fibromyalgia patients based on 2 or more medical claims with a diagnosis of fibromyalgia from January 2008 to February 2009. They designated the date of the first fibromyalgia diagnosis as the index date for each patient.

To qualify for inclusion, each patient had continuous enrollment 6 months pre-index and 12 months post-index, with no pre-index FM diagnosis. Each patient also had 1 pharmacy claim for an fibromyalgia guideline medication (eg, pregabalin, gabapentin, duloxetine, milnacipran, amitriptyline, SSRIs) or for any opioid on or within 6 months after the index date.

The researchers evaluated patterns of treatment initiation and subsequent changes (discontinuation, switch, augmentation) using descriptive statistics and chi-square tests.

Nearly three-quarters (72.5%) of the cohort of 96,175 patients were female (mean age of 47.3 years). The most frequently prescribed first medication (59%) was an opioid, with tramadol constituting roughly 17% of the first post-index opioid prescriptions. Other prescribed medications included AEDs (10%), SSRIs (22%), SNRIs (6%), and TCAs (3%). The authors reported that pre-index use of these medications “was substantial, including 28%-55% of patients using opioids across the prescription categories.”

Pain-related comorbidities were highly prevalent among this patient group, especially musculoskeletal conditions (present in more than 57% of patients). Patients prescribed AEDs or opioids “generally had the highest prevalence across pain-related comorbidities,” according to the authors.

Overall, 20% of the cohort remained on their first prescribed medication; 36% discontinued treatment; 35% augmented treatment with another medication class; and 10% switched medication class. Patients initiated on opioids had the highest rate of discontinuation (48%; P < .001 vs. each of the other classes). Patients prescribed TCAs had the highest switch rate (24%). Half (50%) of the patients prescribed AEDs augmented treatment with another medication (this was the highest augmentation rate for any drug class).

The authors reported that “the most frequently ‘switched-to’ medications were opioids (mainly short-acting) and SSRIs, and these were also the two medications most frequently used for augmentation.”

Based on these results, the authors concluded that opioids were the most commonly prescribed treatment for patients diagnosed with fibromyalgia, with many patients never receiving a guideline-recommended medication. They reported that most patients also “changed or augmented therapy, frequently with opioids. The reasons for these patterns, and their impact on patient and economic burdens, warrant further investigation.”