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Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76:318-328. PMID 27377815

One-paragraph summary

A multidisciplinary working group from 12 countries (rheumatology, pain medicine, epidemiology, health psychology, two patient representatives) replaced the largely expert-opinion 2008 EULAR recommendations with a version built exclusively on systematic reviews and meta-analyses (search to May 2015: 2,979 titles → 275 full papers → 107 eligible reviews), graded with GRADE, with pain, fatigue, sleep, and daily functioning as the key outcomes. The only therapy-based recommendation graded "strong for" was exercise. All other endorsed therapies — psychological therapies, pharmacotherapy (duloxetine, milnacipran, pregabalin among those evaluated), multimodal rehabilitation, and various physical/CAM modalities — were graded "weak for" or lower. Management is organized as a graduated pathway anchored in shared decision-making: (1) education plus non-pharmacological therapy first for all patients; (2) on non-response, therapy individualized to the clinical problem — psychological therapy for mood/coping problems, drugs for severe pain or sleep disturbance, multimodal rehabilitation for severe disability.

Key findings

  • Exercise: sole "strong for" recommendation, on the strength of meta-analytic consistency (effect sizes still modest; see the aerobic Cochrane numbers in bidonde-2017-aerobic-exercise.md).
  • All drug recommendations "weak for"; the paper states plainly that "the size of effect for most treatments is relatively modest."
  • Education and non-drug therapy are formally sequenced before pharmacotherapy — a reversal of the 2008 document's pharmacologic emphasis (contrast documented by Thieme 2017, PMID 28034828).
  • Research agenda: identify which patients benefit from which intervention (treatment-response prediction), effects of combinations, and health-system organization.

Limitations

  • Evidence base frozen at May 2015: predates TNX-102 SL, digital ACT (PROSPER-FM), the confirmatory low-dose-naltrexone trial, and most neuromodulation RCTs.
  • Reviews-of-reviews design inherits the primary literature's short trial durations, LOCF imputation, and enrichment designs.
  • Recommendation tiers compress heterogeneous certainty: "weak for" spans duloxetine (large trial base) and hydrotherapy (small trial base).
  • Little operational guidance on exercise prescription (type, dose, progression) — flagged by the physiotherapy appraisal (Arumugam 2019, PMID 30852147).

Why it matters

The pivot document of modern FM management: a major rheumatology society formally demoting drugs below exercise and education, on GRADE-processed meta-analytic evidence. Nearly every subsequent guideline, review, and trial-justification paragraph cites it; its "graduated approach" is the shared skeleton of stepped care across the EULAR/Canadian/German/NICE family, and its unanswered research agenda (who responds to what) remains the field's central clinical question.

Cited by wiki pages

  • guidelines
  • non-pharmacologic-therapy
  • pharmacologic-therapy