Managing Fibromyalgia
KEY POINTS
● Fibromyalgia (fibrositis) is a heterogeneous chronic soft-tissue rheumatic disorder marked by widespread musculoskeletal pain associated with headache, sleep disturbances, fatigue, and decreased stamina.1,2 [Goldenberg, 2004, Stanford, 2009]
● Other associated features of fibromyalgia include anxiety, depression, diffuse abdominal pain, variable bowel habits, and urinary frequency.3 [Carville, 2008]
● Fibromyalgia is the second most common disorder seen by rheumatologists, with a prevalence of 3.4% in women and 0.5% in men.1 [Goldenberg, 2004]
Diagnosis
● The diagnosis of fibromyalgia is based on a history of pain affecting all four body quadrants and the spinal area for at least three consecutive months.4,5 [Burkhardt, 2005; Wolfe, 1990]
● Pain must be present at 11 of 18 specific anatomic locations (Figure 1) when palpated with a force of 8.8 lbs (4 kg) (Table 1).5 [Wolfe 1990]
● For anatomic point to be considered positive, the patient must report that the palpation was painful. Tender is not considered painful.5 [Wolfe, 1990]
● Fibromyalgia is classified into three types:
• Primary or idiopathic fibromyalgia – Absent an inciting or precipitating event
• Secondary fibromyalgia – Subsequent to an illness, such as an infectious disease or rheumatic disorder
• Posttraumatic fibromyalgia – the result of an injury, such as a fall or motor vehicle accident.6 [Romano, 2008]
● The most severe cases of fibromyalgia tend to be secondary or posttraumatic.6 [Romano, 2008]
● Assessment includes history and physical exam, focusing on conditions that can mimic fibromyalgia (Table 2).4 [Burckhardt, 2005]
● Assess the severity of other medical and cognitive symptoms, including fatigue, sleep disturbance, and mood disorder. Refer suspected mood disorders for psychological testing.4 [Burckhardt, 2005]
● Blood tests include complete blood count, erythrocyte sedimentation rate, muscle enzymes, liver function, thyroid function and other tests to rule out conditions with similar symptoms (Table 2).4 [Burckhardt, 2005]
Treatment
● Optimal management requires a multidisciplinary approach with a combination of pharmacologic and non-pharmacologic treatment that is tailored according to a patient’s pain intensity, level of function, and associated medical and cognitive features (Table 3).3 [Carville, 2008]
Pharmacologic Therapies
● Three drugs have been approved by the Food and Drug Administration for the treatment of fibromyalgia: pregabalin (Lyrica), duloxetine HCL (Cymbalta), and milnacipran HCL (Savella)7,8,9 (Table 4).
● A gradual dose reduction is recommended when discontinuing treatment with duloxetine or milnacipran. 7,8
● Monitor adolescent and young adult patients taking duloxetiene or milnacipran for increased risk of suicidal thinking or behavior.7,8
● Antidepressants such as amitriptyline, fluoxetine, duloxetine, milnacipran, moclomemine and pirlindole may reduce pain and improve function.3 [Carville, 2008]
● Antidepressants may be prescribed for sleep.4 [Burckhardt, 2005]
● Sleep and anti-anxiety medications may be prescribed for sleep disturbances such as restless leg syndrome.4 [Burckhardt, 2005]
● Selective serotonin reuptake inhibitors (SSRIs), alone or in combination with tricyclic antidepressants, may be prescribed for pain relief.4 [Burckhardt, 2005]
● Do not use non-steroidal anti-inflammatory drugs (NSAIDs) as primary pain medication. NSAIDs may provide some analgesia when given with other drugs.4 [Burckhardt, 2005]
● Tramadol (Ultram) 50 to 100 mg bid or tid daily may be prescribed for pain relief with or without acetaminophen.4 [Burckhardt, 2005]
● Corticosteroids should not be used unless the patient also has a bursa or tendon inflammation.4 [Burckhardt, 2005]
● Opioids should be used only after all other pharmacologic and nonpharmacologic therapies have been exhausted.4 [Burckhardt, 2005]
Non-Pharmacologic Therapies
● Heated pool treatment with or without exercise is effective in fibromyalgia.3 [Carville, 2008]
● An individually tailored fitness program, including aerobic exercise and strength training, can help improve pain and function.3 [Carville, 2008]
● Cognitive behavioral therapy (CBT) may be beneficial for some patients. CBT can help improve symptoms including physical functioning, pain and sleep disturbances.10 [Starz]
● Other therapies such as relaxation, rehabilitation, physiotherapy and psychological support may be used depending on the needs of the patient.3 [Carville, 2008]
Patient Education
● Explain the diagnosis of fibromyalgia and the nature of the condition.4 [Burckhardt, 2005]
● Ask patients about their use of complementary products and practices and answer questions concerning efficacy and identify possible negative interactions with prescribed treatment.4 [Burckhardt, 2005]
● Discuss the possible increased risk of suicidal behavior and thinking among children, adolescents and young adults taking medication.
FOOTNOTES
1. Goldenberg DL, Burckhardt CS, Crofford L. Management of fibromyalgia. JAMA. 2004;292:2388-2395.
2. Stanford SB. Fibromyalgia: psychiatric drugs target CNS-linked symptoms. Curr Psychiatr. 2009;8;37-50.
3. Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia. Ann Rheum Dis. 2008;67:536-541.
4. Burckhardt CS, Goldenberg DL, Crofford L, et al. Guideline for the management of fibromyalgia syndrome pain in adults and children. Glenview (IL):American Pain Society; 2005.
5. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33:160-172.
6. Romano TJ. Fibromyalgia in the clinic and the courtroom. Pain Practitioner. 2008;18:13-17.
7. Cymbalta (duloxetine HCL) Delayed-Release Prescribing Information, Eli Lilly & Co., Indianapolis, IN.
8. Savella (milnacipran HCL) Prescribing Information, Forest Laboratories, New York, NY, and Cypress Bioscience, San Diego, CA.
9. Lyrica (pregabalin) Prescribing Information, Pfizer, New York, NY.
10. Starz TW, Vogt MT. Fibromyalgia: it’s not all in my head. Pain Practitioner. 2008;18:62-70.
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Figure 1. Specific Location of Tender Points in Fibromyalgia
This image is from numerous sources. Change arrow labels to the below, which is from the 1990 ACR Criteria for the Classification of Fibromyalgia — http://www.rheumatology.org/publications/classification/fibromyalgia/fibro.asp
Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.
Table 1. Manual Tender Point Survey [STARZ, 2008]
o Instruct patient that various areas of the body will be examined and to say Yes or No if pain is felt at specific points.
o Ask patient to rate the intensity of pain on a scale from 0 to 10, where 0 is no pain and 10 is the worst pain ever experienced.
o Assess the presence and intensity of pain at 18 survey and 3 control sites:
Survey and Control* Sites
Seated Right Left
Mid-Forehead* 1. *
Occiput 2. 3.
Trapeziuz 4. 5.
Supraspinatus 6. 7.
Gluteal 8. 9.
Low Cervical 10. 11.
2nd Rib 12. 13
Bilateral Epicondyle 14. 15.
Dorsum R Forearm* 16. *
L Thumbnail 17. *
Side
Greater Trochanter 18. 19.
Supine
Knee 20. 21.
Positive Survey Sites: Total Survey Site Scores (SS):
Positive Control Sites: Total Control Site Scores (CS:
Fibromyalgia Intensity Score (SS / 18):
Control Intensity Score (CS / 3):
Table 2. Differentiating Fibromyalgia from Illnesses with Similar Symptoms [Stanford, 2009]
Illness Tests to Differentiate from Primary Fibromyalgia
Rheumatic Diseases
Osteoarthritis
Spondyloarthropathies, rheumatoid arthritis
Systemic lupus erythematosus, polymyalgia rheumatica
Osteomalacia
Myopathy
Radiographs
Antinuclear antibody, rheumatoid factor, antibodies
Erythrocyte sedimentation rate, C-reactive protein
Vitamin D level
Creatine phosphokinase
Neurologic
Multiple sclerosis, Chiari’s malformation, spinal stenosis, radiculopathy
Neuropathy
Magnetic resonance imaging
Electromyography
Endocrine
Hypothyroidism
Diabetes
Thyroid-stimulating hormone
Basic chemistry panel with fasting glucose
Other
Lyme disease
Hepatitis
Anemia
Cancers
Complete blood count, Lyme titer
Complete blood count, liver function tests
Hemoglobin and hematocrit
Routine cancer screening tests, bone scan, blood chemistries specific for suspected primary cancer.
Table 3. Medical and Cognitive Features Related to Fibromyalgia [Stanford 2009]
Neurologic
Tension/migraine headache
Ear, Nose and Throat
Sicca symptoms
Vasomotor rhinitis
Vestibular complaints
Cardiovascular
Neurally mediated hypotension
Mitral valve prolapse
Noncardiac chest pain
Gastrointestinal
Esophageal dysmotility
Irritable bowel syndrome
Urological
Interstitial cystitis
Gynecological
Vulvodynia
Chronic pelvic pain
Oral/Dental
Tempromandibular joint syndrome
Other (General)
Chronic fatigue syndrome
Sleep disturbances
Idiopathic low back pain
Multiple chemical sensitivity
Table 4. Pharmacologic Treatment of Fibromyalgia
Drug Dosage Form (See specific product labeling for complete prescribing information.) Admin
Route Usual Adult Dose Maximum
Daily Dose
Pregabalin (Lyrica)9*
Capsules: 25 mg, 50 mg, 75 mg, 100 mg, 200 mg, 225 mg, 300 mg PO • Begin dosing at 150 mg/day
• Give in 2 divided doses
• May be increased to 300 mg/day within 1 week 450 mg/day
Duloxetine HCL (Cymbalta)7*,+ Capsules: 20 mg, 30 mg, 60 mg PO • Recommended dose 60 mg once daily
• Some patients may benefit from starting at 30 mg once daily
• No evidence that doses over 60 mg/day confers benefit 60 mg/day
Milnacipran HCL (Savella)8*,+ Tablets: 12.5 mg, 25 mg, 50 mg, 100 mg PO 50 mg bid
Dosing should be titrated;
Day 1: 12.5 mg
Day 2-3: 12.5 mg bid
Day 4-7: 25 mg bid
After Day 7: 50 mg bid 200 mg/day
* Black box warning: may increase risk of suicidal thinking or behavior in children, adolescents and young adults. + Not approved for pediatric patients.