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Medications prescribed and appropriate treatment methods differ significantly depending on the clinical condition but share core principles of personalized care, minimization of polypharmacy, and a preference for first-line non-pharmacological approaches.

For borderline personality disorder (BPD), current UK NICE guidelines advise against routine pharmacological treatment except in acute crisis situations NICE CG78. Psychotherapy is the first-line and mainstay treatment, focusing on symptom-specific relief and improving function NICE CG78. There is no approved pharmacological treatment for BPD, and pharmacotherapy plays an adjunctive role primarily for co-occurring psychiatric symptoms rather than targeting BPD directly NICE CG78 White et al. 2026. Despite this, real-world data from the US show that antidepressants are most commonly prescribed (notably SSRIs such as sertraline, fluoxetine, and citalopram), often combined with second-generation antipsychotics (SGAs) like quetiapine and aripiprazole or mood stabilisers such as lamotrigine and gabapentin White et al. 2026. However, high rates of polypharmacy (83% or more) occur, which is not entirely aligned with guidelines and may increase treatment burden and risk NICE CG78 White et al. 2026. Pharmacotherapy, when used, targets comorbid mood, anxiety, or impulsivity symptoms and is recommended for short-term crisis intervention rather than long-term management NICE CG78 White et al. 2026. Given the complexity and symptom heterogeneity, treatment stability is often low, with frequent medication switches and combinations White et al. 2026.

In contrast, fibromyalgia (FM) management involves both pharmacological and non-pharmacological strategies aimed primarily at pain relief, improving sleep quality and managing cognitive symptoms often described as fibro-fog Lopez de Coca et al. 2026. UK guidelines emphasize multifaceted treatment, but consensus on specific drugs is limited Lopez de Coca et al. 2026. The European League Against Rheumatism (EULAR) recommendations endorse low-dose amitriptyline, duloxetine or milnacipran, pregabalin, cyclobenzaprine, and tramadol as pharmacological options with varying levels of evidence and recommend integrating psychological and physical therapies Lopez de Coca et al. 2026. These drugs primarily aim to restore neurotransmitter balance involved in pain modulation (increasing serotonin, norepinephrine, and GABA activity) Lopez de Coca et al. 2026. Yet, real-world data reveal high use of antidepressants (notably duloxetine and SSRIs), analgesics including opioids such as tramadol, anxiolytics including benzodiazepines (BZPs), and anticonvulsants like pregabalin and gabapentin, some of which have high anticholinergic burden contributing to cognitive impairment risks Lopez de Coca et al. 2026. Notably, 50.9% of FM patients show a significant anticholinergic load, increasing risk of central nervous system (CNS) depression, sedation, and serotonin syndrome, especially when opioids and BZPs are combined, posing safety concerns that require regular medication review and deprescribing where possible Lopez de Coca et al. 2026.

Deprescribing and medication review are essential strategies across clinical contexts to reduce polypharmacy risks, adverse drug events, and medication burden, especially in older adults or patients on complex regimens Matos and Pinheiro C. 2026. Deprescribing involves a systematic, patient-centered approach to identify and discontinue medications that are no longer beneficial or potentially harmful, considering individual risk-benefit balance, patient preferences, and clinical indications Matos and Pinheiro C. 2026. Multidisciplinary collaboration among healthcare professionals including pharmacists is vital for safe and effective deprescribing Matos and Pinheiro C. 2026. Tools like STOPP/START and Beers criteria assist in detecting potentially inappropriate medications, particularly psychotropics, NSAIDs, proton pump inhibitors, and benzodiazepines commonly implicated in harms in older adults Matos and Pinheiro C. 2026.

Summary of prescribing principles and treatment methods:

• For BPD, prioritize psychotherapy; reserve pharmacological treatment primarily for acute crisis or comorbid symptoms; favor SSRIs as first-line medications if used; avoid long-term polypharmacy due to lack of evidence and increased risks NICE CG78 White et al. 2026.
• For FM, use guideline-recommended drugs such as low-dose amitriptyline, duloxetine, pregabalin, and tramadol judiciously; limit use of benzodiazepines and opioids given safety concerns; monitor for anticholinergic burden and CNS depression; integrate non-pharmacological therapies like exercise, psychological modalities, and dietary interventions Lopez de Coca et al. 2026 Lopez de Coca et al. 2026.
• Across populations, regularly conduct medication reviews and deprescribing to minimize polypharmacy and adverse outcomes; engage multidisciplinary teams including pharmacists in optimizing therapeutic regimens; apply tools like STOPP/START for identifying inappropriate medications, especially in elderly or complex patients Matos and Pinheiro C. 2026.

Appropriate treatment methods include combining pharmacological interventions with psychosocial support, physical therapies, and lifestyle modifications to optimize symptom control while minimizing iatrogenic risks NICE CG78 Lopez de Coca et al. 2026 Matos and Pinheiro C. 2026.