Entering by several patient associations, the High Authority for Health (HAS) publishes the first recommendation aimed at defining and improving the diagnosis and management of adults with fibromyalgia. Listening to patients and recognition of their suffering are a prerequisite for their commitment to care, essentially non -drug.
Fibromyalgia has been a chronic disease recognized by the World Health Organization since 2019. It would affect 1.5 to 2 % of the population in France and three times more women than men. Diffuse and prolonged chronic pain (beyond 3 months) is the main symptom, but it can often be associated with intense fatigue, sleep disorders, anxious, depressive or cognitive disorders, impacting quality of life. These symptoms fluctuate in time in the same person and can be different from one person to another. The diagnosis of fibromyalgia is difficult to establish and no biological or radiological examination makes it possible to affirm it. It is based on a clinical examination, active listening to the patient and the use of evaluation tools (self-questionnaire, diagnostic criteria, algorithms, etc.).
After having published in 2010 an inventory of available data concerning adult fibromyalgic syndrome, HAS was entered by several patient associations to develop recommendations on the diagnostic approach and therapeutic strategy intended for professionals[1] accompanying adult patients. These recommendations are based on the guide to the health course of a person with chronic pain developed in 2023, for organizational aspects.
The main challenge of this new recommendation is to help people with fibromyalgia live better with pain. For patients, it is to improve their understanding of both symptoms and impact and how to get involved in their treatment. It is also a question of preventing the risks linked to ineffective, even dangerous practices.
Recognize the suffering of people and engage them in their care
Once the diagnosis is made and the impact on the quality of life evaluated, it is essential to recognize the suffering of the patient. Otherwise, it will be difficult to mobilize him in his care. After listening to the patient, an explanation phase of the disease or the treatment options is necessary. The HAS will publish an information document intended for the patient at the end of September, which can be used in support. This exchange time is also an opportunity to inform the patient about the possibility of contacting patient associations to find another form of listening and support.
Put the person back in motion and help them adapt to the disease
Like fibromyalgia fluctuating symptoms, the therapeutic strategy is evolving. It is based on non -drug treatments with On the front line the physical activity Supervised by a professional of adapted physical activity. The HAS offers a typology of physical exercises taking into account the specificities linked to fibromyalgia. Teaching the person to better manage the symptoms on a daily basis and to continue their personal and professional activities, by involving the care team, is an essential complement of treatment.
The objective of this patient/professional therapeutic alliance is to set up Disease adaptation and self -management strategies (alternating periods of activity and rest, participation in therapeutic education sessions, development of the workstation, etc.) and to reassess them regularly, if not being able to offer curative treatment. It is also important to remain vigilant to any form of vulnerability and a risky or present risk situation. The use of other professionals (psychologist, psychiatrist, social worker, etc.) may then be necessary for a in -depth psychological, social or professional assessment and suitable support.
Watch out for misuses and risks associated with drug treatments
To date, no marketing authorization for a drug has been granted in France in the indication of fibromyalgia. Some antidepressants and antiepileptics can be prescribed in low doses to relieve pain, but their benefit expected in fundamental treatment remains modest. These drugs come in the second line, after evaluating the effects of physical activity and self -management strategies for fibromyalgia. Any prescription is to be discussed with the patient. Caution to be careful with opioids: their appeal must remain exceptional in the long run and their prescription made after a specialized opinion. Particular attention should be paid in case of misuse.
The HAS makes tools available to professionals to help diagnosis and care: self-questionnaire, diagnostic criteria, algorithms … An “appointment of good practices” will be organized on September 30: experts from the working group will present the recommendations online and answer live questions. Registrations are open.
To allow professionals to appropriate these works
The has proposed:
- Recommendations.
- A summary of essential messages to improve practices.
- Tools to help diagnosis and graduate the therapeutic strategy: self-questionnaire, diagnostic and monitoring criteria for fibromyalgia severity, algorithms for the diagnostic approach and graduated therapeutic strategy.
Messages clés- Le diagnostic de la fibromyalgie est clinique en l’absence de biomarqueurs spécifiques.
- L’annonce du diagnostic de fibromyalgie permet de reconnaître la souffrance et de légitimer la plainte. Elle s’accompagne d’explications approfondies et personnalisées sur la maladie, ses mécanismes et les options de traitement, ce qui facilite l’engagement du patient et la coconstruction du projet de soins.
- Le médecin généraliste coordonne la mise en œuvre du projet de soins, ainsi que les intervenants impliqués dans les soins.
- La stratégie thérapeutique est graduée et personnalisée avec en 1ère ligne l’activité physique incluant un apprentissage en autonomie, des stratégies personnalisées d’autogestion de la maladie, le maintien dans l’emploi, l’accompagnement de toute forme de vulnérabilité.
- En 2ème ligne, les traitements pharmacologiques doivent ĂŞtre dĂ©butĂ©s Ă faibles doses avec une augmentation progressive et prudente de la posologie, afin d’amĂ©liorer la tolĂ©rance et rĂ©duire l’apparition d’effets indĂ©sirables.Â
- Certains antidépresseurs et antiépileptiques peuvent être prescrits pour les douleurs continues en traitement de fond, des antalgiques usuels pour les douleurs incidentes de façon ponctuelle, jamais au long cours. Le recours aux opioïdes pour les douleurs aigües incidentes doit être prudent et ponctuel, et exceptionnel au long cours.
- Lors de chaque renouvellement du traitement médicamenteux : évaluer la tolérance et l’efficacité ressentie, identifier un mésusage et les risques associés.
- Tout au long du suivi, repérer, évaluer et traiter d’éventuels troubles psychiques (anxiété, dépression, idéation suicidaire).
- Les situations de surpoids et d’obésité sont à évaluer et à traiter.
- Les régimes alimentaires proposant des restrictions spécifiques (par exemple, sans gluten, sans lactose, etc.), la prise de compléments alimentaires, n’ont pas d’intérêt démontré dans la fibromyalgie en dehors de carences avérées.
- D’autres interventions sans effets indésirables, ni risques pour la santé comme les soins thermaux, la relaxation, l’hypnose, la méditation, peuvent être discutées dans le cadre du projet de soins sous certaines conditions et modalités de délivrance, de formation appropriée des intervenants et d’arrêt en cas de non-réponse.
- En 3ème ligne, des techniques de neurostimulation peuvent être proposées après avis.
- Les associations de patients informent, partagent leur expérience, participent à l’éducation thérapeutique du patient, rappellent la vigilance à avoir vis-à -vis de certaines pratiques.
- Le recours à une structure spécialisée en douleur chronique (SDC) peut être nécessaire pour un avis, des conseils, une évaluation multidisciplinaire et pluriprofessionnelle, le choix d’un traitement, en cas de douleurs résistantes, de difficultés de coordination.
[1] General practitioners, other specialist doctors (rheumatology, internal medicine, neurology, physical medicine and rehabilitation, etc.), doctors and nurses Resources of chronic pain structures, doctors and nurses for occupational prevention and health services, adapted physical activity professionals, coordinated nurses (including Asalée and IPA), pharmacists, psychologists social workers
