Fibromyalgia

Question 1

What neurotransmitters are decreased in the CSF in patients with fibromyalgia?

Answer 1

NE, DA, and 5-HT

Question 2

Describe the process of dysregulation of fibromyalgia.

Answer 2

The hypothalamus-pituitary axis is dysregulated. That causes an increase in Corticotropin-releasing hormone and substance P activity. This leads to an increase in proinflammation and neurosensitizing molecules.

Question 3

Describe two common signs/symptoms of fibromyalgia.

Answer 3

Allodynia, which is increased sensitivity to stimuli that aren’t normally painful.

Hyperalgesia, which is an increased sensitivity to painful stimuli.

Question 4

What are some of the main assessments/indexes used to score and assess fibromyalgia?

Answer 4

Widespread Pain Inex (WPI)
Symptom Severity (SS)

Question 5

What are the goals of therapy in relation to fibromyalgia?

Answer 5

Improve function

Reduce pain symptoms

Question 6

What are some different pharmacologic therapies to use to treat fibromyalgia?

Answer 6

Gabapentin
SNRIs
TCAs
Skeletal muscle relaxants
Dopamine agonists

Question 7

What are the doses for treatment of pain syndromes compared to depression/anxiety?

Answer 7

You will use lower doses for drugs that are being used for pain compared to when they are being used for depression/anxiety.

Question 8

Gabapentinoids

MOA, ADRs, Dose adjustments

Answer 8

Gabapentin and pregabalin
MOA: Binds to sites associated with presynaptic voltage-gated Ca channels, which modulates excitatory NT release involved in nociception.
ADRs: Dizziness, Increased weight, sedation
DA: Renal adjustments

Question 9

SNRI drugs

Answer 9

Duloxetine, venlaflaxine, milnacipran

Question 10

SNRI MOA

Answer 10

Inhibits reuptake of synaptic 5-HT and NE

Question 11

SNRI ADRs

Answer 11

Increased BP, HR

Nausea, sweats, HA, dry mouth

Question 12

SNRI Interactions

Answer 12

Duloxetine is a CYP1A2 substrate
Venlafaxine is a CYP3A4 and 2D6 substrate
Duloxetine/venlafaxine are CYP2D6 inhibitors

Question 13

SNRI dose adjustments

Answer 13

Renal adjustments

Hepatic adjustments

Question 14

Tricyclic Antidepressant (TCAs) Drugs

Answer 14

Amitryptyline

Nortriptyline

Question 15

TCA MOA

Answer 15

5HT and NE reuptake inhibition

Question 16

TCA ADRs

Answer 16

Dry mouth
Increased weight
Somnolence
GI disturbances
Increased QT wave

Question 17

TCA Interactions

Answer 17

Interacts with anticholinergic agents, MAOIs, and other serotonergic agents
Other QT prolonging agents
Amitriptyline and nortripyline are CYP2D6 substrates

Question 18

TCA dose adjustments

Answer 18

No renal or hepatic recommendations

Question 19

Skeletal Muscle Relaxant Drugs

Answer 19

Cyclobenzaprine

Question 20

Skeletal Muscle Relaxants MOA

Answer 20

Acts at the brainstem to modulate tonic somatic motor activity

Question 21

Skeletal Muscle Relaxant ADRs

Answer 21

Drowsiness
Dizziness
Dry Mouth
Constipation
Increased Heart Rate

Question 22

Skeletal Muscle Relaxant Interactiosn

Answer 22

MAOIs and other serotonergic agents

CYP1A2 Substrate

Question 23

Skeletal Muscle Relaxant Dose Adjustments

Answer 23

Hepatic Adjustment

Question 24

Dopamine Agonists

Answer 24

Pramipexole

Ropinirole

Question 25

DA Agonist MOA

Answer 25

May help modulate excessive adrenergic arousal (helps with sleep in fibromyalgia)

Question 26

DA agonist ADRs

Answer 26

Orthostatic hypotension
Drowsiness
Dizziness
Impulse control
Extrapyramidal symptoms

Question 27

DA agonist Interactions

Answer 27

Antipsychotics

Ropinirole reacts with CYP1A2 Substrates

Question 28

DA agonist Dose Adjustments

Answer 28

Renal Adjustment