Fibromyalgia

Question 1

What is it and how does Fibromyalgia occur?

Answer 1

Pain dysregulation disorder

How?

• central sensitisation mechanism
• there can be evidence of psychoneuroimmune, cortical, endocrine dysfunction and widespread small fibre sensory polyneuropathy

Why?

• Poorly understood
• Historically thought to be solely related to physical or psychological trauma
• Although emotional/physical distress can be a factor, occurs without it
• likely a significant genetic susceptibility

Question 2

Who does Fibromyalgia impact?

Answer 2

Who?
-2 - 5% prevalence
-women > men
-can occur at any age, but tends to be from late teens to middle age, peak between 30 -60yo
-about 30% of patients with local chronic pain disorders will develop fibromyalgia
-often coexists with other chronic conditions:
41% of those with Rheumatoid Arthritis
18% of Type 2 Diabetes
22% with chronic heart failure

Question 3

Fibromyalgia Symptoms/Diagnosis?

Answer 3

1) Widespread pain
- often has a burning, “neuropathic” quality
- previous ‘tender points’ have no scientific basis so are no longer clinically relevant

May also have any of the following:

• sleep disturbance
• fatigue
• cognitive changes (‘brain fog’)
• mood disturbances
• other somatic complaints - most commonly all-day stiffness

2) Exclude
a) RED FLAGS
- focal pain
- neurological symptoms
- night pain
- history of malignancy
- weight loss
- anorexia
- night sweats

b) No other cause identified with the following investigations:
- CBE, CMP, ESR, CRP, TSH, CK, ANA, Vit D
* differing opinions about Anti-CCP and RhF - Yes/No

Question 4

FIbromyalgia management?

Answer 4

Management:

1) Promote self-efficacy
- education about disease
- Chronic disease self-management
- Address psychosocial issues
- support/encourage continued employment or volunteer work

2) Physical activity
- Best evidence for Tai Chi and aerobic exercise

3) Psychological intervention
- CBT
- Mindfulness

4) Medication
Low Dose Naltrexone
-1-5mg/day
-nocte dosing unless dreams are an issue
-weekly up titration as tolerated

*can be taken while on opioids
-trial of 3 months is reasonable

Possible mechanisms of action
-antagonise Toll Like Receptor 4 in glial cells resulting in reduced inflammatory and nociceptive activation in nervous system
-Neuroprotective
-reactive upregulation of endogenous opioids

Side effects
-vivid dreams
-insomnia
-GIT disturbance

Positive effects
-improved mood, quality of life and less stress
-reduction in inflammatory markers
-reduction in pain or increase in pain tolerance

(LAST RESORT)
- Amitriptyline 10 - 50mg
- Pregabalin 75 - 600mg
- Duloxetine 30 - 120mg
- Tramadol and Paracetamol (37.5/325mg)
* attempt to avoid opioids as they further sensitise people to pain and can induce hyperalgesia