Fibromyalgia

Q: Fibromyalgia is combination of widespread chronic musculoskeletal pain, fatigue and sleep disturbance. Which of the following medication is NOT FDA approved for fibromyalgia treatment?


 

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Fibromyalgia is combination of widespread chronic musculoskeletal pain, fatigue and sleep disturbance.


PATHOPHYSIOLOGY:

Amplification of peripheral sensory signals, so normal sensations are perceived painful.


CO-EXISTING CONDITIONS:

    • Other functional pain syndrome (vulvodynia, interstitial cystitis, temporomandibular joint pain, chronic back pain, endometriosis, and noncardiac chest pain)

    • Mood disorder

  • PTSD


DIAGNOSTIC CRITERIAS:

Note that 1990 American College of Rheumatology diagnostic criteria for fibromyalgia were based on presence of at least 11 of 18 designated tender point sites, and widespread chronic pain.

Fibromyalgia is now diagnosed by updated set of clinical criteria that no longer depend on tender point examination, but focuses on clinical symptoms.   

American College of Rheumatology 2010 Diagnostic Criteria for fibromyalgia:

    1. Widespread pain index >7 and symptoms severity score >5, or widespread pain index =3-6 and symptom severity score >9

    1. Symptoms greater than at least 3 months.

  1. Patient does not have a disorder that would explain pain.


Detailed criteria available on AAFP website here: 

https://www.aafp.org/afp/2015/0401/hi-res/afp20150401p472-f2.gif


LABORATORY TESTING:

  • Laboratory testing is not needed for diagnosis.

  • But testing for chronic fatigue for anemia, thyroid disorder & electrolyte disturbance is recommended.


MANAGEMENT:

(1) Pharmacotherapy

    • Duloxetine, Milnacipran and Pregabalin are FDA approved for fibromyalgia treatment.

    • SNRIs like duloxetine, TCA like amitriptyline, Anti-epileptics like pregabalin and Muscle relaxer like cyclobenzaprine have strong evidence of benefit for improving pain, fatigue, sleep problems & quality of life.

    • Among antidepressants: Short-term usage of amitriptyline and duloxetine can be considered for the treatment of pain and sleep disturbances.

  • Use of opioids is controversial, should be used carefully in selected patients if alternative therapies not working.

2. Exercise:

    • Aerobic exercise (land-based or water-based exercises)

    • moderate intensity for 20-30 minutes

    • 2-3 days a week

  • at least 4 weeks

 

This has shown strong evidence in improving symptoms.

The patient should be motivated to continue exercise after participating in an exercise program.

3. Patient education:

Discuss expectations for treatment, consider symptom diaries.

4. Symptom relief:

Target medication to prioritize symptoms, start low and slowly titrate.

5. Treat coexisting problems:

mood, sleep disorder and functional pain.

6. Non-pharmacologic therapies:

    • Sleep hygiene

    • Physical activity

  • CBT.

Write them as prescription.


Source:

  1. Am Fam Physician. 2015 Apr 1;91(7):472-478.

  2. Arthritis Rheum. 1990;33(2):160–172.

  3. Am J Health Syst Pharm. 2011;68(14):1307–1319.

  4. JAMA. 2009 Jan 14;301(2):198-209.

  5. Arthritis Res Ther. 2010;12(3):R79.


Post by Dr. Satinderpal Kaur, M.D.


 

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