fibromyalgia Flashcards
1
Q
- common and complex pain disorder that causes widespread pain and tenderness to touch that may occur body wide or migrate over the bodym and can wax and wane overtime
- usually associated with wide array of other symptoms
- affects people physically, mentally and socially
A
fibromyalgia
2
Q
who does fibromyalgia usually affect?
A
- 2:1 female to male predominance
- age of onset between 20-50
- patients make on average 10 outpatient clinic visits per year
3
Q
what is the pathophysiology of FM?
A
- abnormal sensory processing in the CNS results in pain amplification
- fatigue, sleep problems
- overlapping conditons and other symptoms
- increased levels of substance P in the spinal cord
- low levels of blood flow to the thalamus region of the brain
- HPA axis hypofunction
- low levels of serotonin and trytophan
- abnormalities in cytokine function
4
Q
signs and symptoms of FM?
A
widespread pain > 3 months
fatigue
sleep problems
other signs, symptoms or conditions
diffuse & significant soft tissue tenderness with palpation
5
Q
somatic symptoms and conditons of FM
A
- Irritable bowl and bladder
- headache/migraines
- RLS
- tinnitus; dizziness
- visual impairment
- raynauds
- dry eyes & mouth, anxiety and depression
6
Q
Triggers of fibromyalgia?
A
- acute pain
- infections - EBV, viral hepatitis
- trauma- emotional (bullying) physical (MVA
7
Q
Clinical presentation of fibromyalgia
A
- diffuse musculoskeletal aches (pain all over) or “feel like I have to flu”
- morning stiffness
- paresthesia
- fatigue
- sleep disorder
- cognitive difficulties
- exacerbations with weather changes
8
Q
diagnosis of fibromyalgia?
A
- widespread (multisite pain)
- present for at least 3 montsh
- fatigue, sleep disturbances
- other symptoms such as cognitive disturbances, headaches, bowel irritability
- PE: widepread tenderness, absence of joint swelling, inflammatin
- labs: normal acute phase reactants (ESR/CRP), normal CBC
9
Q
Dignostic labs and imaging in FM?
A
labs
- no specific abnormalities are diagnostic or characteristic
- limited role for lab tests- CBC and CRP at most
- do not screen for RF or ANA unless clinical suspicion for inflammatory rheumatologic condition as the can be positive in healthy adults
Diagnostic imagning
- no role in diagnosis
10
Q
non-pharmacological treatment options for FM?
A
- Patient education
- self management strategies: sleep hygiene, stress mangaement, regular aerobic exercise, weight reduction
- supervised and graded exercise programs and cognitive behavioral interventions are mainstay treatment
- exercise: low impact- aerobic exercises, swimming, walking- start low and go slow
- cognitive behavior therapy is beneficial
- other: acupuncture, biofeedback, chiropractic, yoga, tai chi, massage therapy
11
Q
- Class: TCA
- MOA: neurotransmitter reuptake inhibitor (esepcially norepi and serotonin); anticholinergic
- low dose at night and titrate slowly. Star 10mg po qhs, titrate to 20-30mg for maintenance
- AE: cardiotoxicity, sedation, dry mouth, blurred vision, constipation, weight gain
- caution: Suicide, serotonin syndrome, CNS depression, anticholinergic side effects, wean off
A
Amitriptyline
12
Q
- Muscle relaxant
- indications: muscle spasm, painful musculoskeletal conditions
- MOA: centrally acting skeletal muscle relaxant structurally related to TCA (potential to block out neurotransmitters)
- AE: drowsiness, dizzines, dry mouth
- contraindications: hypersensitivity, during or within 14 days of MAOis, heart disease
A
cyclobenzaprine
13
Q
- SSRI
- Indications: major depressive disorder, eating disorders, OCD, PMDD, panic disorder
- MOA: inhibits reuptake of serotonin
- dose: 20-30mg po am; 60mg maintenance
- AE: nausea, diarrhea, dry mouth, anorexia
- contraindications: hypersens. to drug/class/comp, CrCl < 30, alcohol abuse, avoid abrupt withdrawal
A
Duloxetine
14
Q
- SNRI
- MOA: inhibitor of serotonin and norepinephrine reuptake
- AE: Nausea, constipation, dry mouth, anorexia
- Contraindications: suicidal ideation, chronic liver disease
- caution: < 25 years old, bleeding risk, mania, GI motility disorder, gaucoma, seizure history, HTN
A
Milnacipran
15
Q
- gabapentoids
- indications: DPN, PHN, fibromyalgia, partial-onset seizure, neuropathic pain, from spinal cord injury
- MOA: unknown, GABA analogue, inhibits excitatory neurotrasmitter release
- AE: dizziness, drowsiness, weight gain, peripheral edema
- contraindications: hypersensitivity to pregablin
- caution: misuse/abuse (schedule V) CNS depression, wean off
- Dose adjustment required for renal impairment
A
Pregablin
16
Q
- Gabapentoids
- indications: seizures, post herpetic neuralgia
- MOA: unknown, GABA analogue, similar to lyrica
- AE dizziness, drowsiness, weight gain
- contraindications: hypersensitivity
- caution: CNS depression, wean off
- dose adjustments indicated for renal impairment
A
gabapentin
17
Q
other pharmacologic treatments for FM
A
- tramadol
- NSAIDs
- other opioids
- topical capsaicin
- no proven efficacy for FM treatment
18
Q
other therapies for FM?
A
- acupuncture
- chiropractor treatment
- massage
- myofascial release
- limited evidence, but worth suggesting in combination therapy
19
Q
Combination therapy in fibromyalgia?
A
- patients who do not respond to mono-therapy may benefit from combination therapy
- takes advantage of multiple mechanism of action to reduce pain and target different symptoms
- SNRI (cymbalta) with anticonvulsant (lyrica)
- low dose SSRI (fluoxetine) or SNRI (cymbalta) in AM and TCA (amitryptyline) at bedtime
20
Q
Important things to know about fibromyalgia?
A
- treat in PCP office; no need for referral to rheumatology unless fail to respond with multi-modal therapies
- this is a chronic disease
- design a multidisciplinary approach to treatment- regular exercise, sleep hygiene, active self management
