Fibromyalgia Flashcards
Definition
Generalized pain amplification w/widespread musculoskeletal pain and fatigue, thought due in part to aberrant central pain processing, sleep disturbance, anxiety and depression may contribute/exacerbate symptoms
Synonyms
Myofascial pain syndrome, fibromyositis, fibrositis
1990 ACR criteria
85-90% sensitive, approx. 80% specific, must have both:
- Hx widespread pain present >/= 3 months; pain must be in both sides of body (above and below the waist); axial skeleton pain needs to be present (spine or anterior chest)
- Pain in 11 of 18 tender points upon applying 4 kg pressure (enough o blanch nail bed)
Epidemiology
Affects 2-5% US adults; affects females:males 7:1, average time to diagnosis 5 y
Risk Factors
Depression, anxiety, sleep disturbance, FHx, life stressors, trauma/injury
DDx
Autoimmune disease, (SLE, RA, myositis, PMR), malignancy, drug toxicity (statins), OSA, hypothyroidism, depression, chronic fatigue, lyme
History
Triad of diffuse pain for >3 months; Hs fatigue, sleep disturbance, anxiety, depression; other sx include cognitive difficulties, stiffness, HA, pelvic, abdominal wall and chest pain; screen fro depression, anxiety, sleep apnea, restless leg
Exam
Only findings should be pain in at least 11 of 18 anatomic points; additional findings suggest separate processes
Findings inconsistent with fibromyalgia
Joint swelling, muscle atrophy, rash, alopecia, abnl labs, focal neuro findings (numbness, weakness)
Workup
Labs not necessary to confirm dx, but helpful to r/o other disease
Recommended: ESR, CRP, Chem-12, TFTs, CBC, vitd; consider iron studies
Not recommended: ANA, RF, CCP unless H&P suggestive or if increase ESR/CRP
Prognosis
10-30% of pts are disabled; fibromyalgia does not increase mortality but may be associated with increase risk of suicide
General Treatment Principles
Mainstay to address contributing sleep disturbance/insomnia, anxiety, depression; non-pharmacologic approaches should be tried first; never treat w/opiods, which can amplify pain; APAP may be helpful for pain control during flares.
Pharmacologic treatment
Indicated if persistent/severe sx despite conservative RX; no clear guidance for one agent over another, but can consider starting w/amitriptyline or cyclobenzaprine; duloxetine/milnacipran in AM may help if fatigue is predominant; pregabalin at night helpful for severe Non
Nonpharmacologic
Educate about ds, tx, prognosis, sleep hygiene, manage expectations, reassure about benign nature, validate that this is a real disease
Physical activity
Improves function, pain, mood, fatigue; tai Chi more effective than wellness education + stretching
CBT
Improve coping, pain, fatigue, mood, anxiety
Acupuncture, massage, yoga
along w/mind-body center referral may decrease pain
Amitriptyline
start 5-10mg QHS; increase to 25-50mg QHS
Decrease pain, sleep disturbance, fatigue
Constipation, dry mouth, increase wt, decrease concentration
Cyclobenzaprin
Start 10mg QHS, increase to 10mg QAM and 20-30mg QHS
Decrease pain and fatigue, less antidepressant effect
Sedation, dry mouth, dizziness, GI upset
Pregabalin
Start 75mg BID, increase to 150-225mg BID
Decrease pain, increase fibromyalgia ratings vs placebo
Dizziness, dry mouth, increase wt, somnolence
Duloxetine (SNRI)
Start 30mg/d, increase to 60mg/d
Decrease pain, increase fibromyalgia ratings vs placebo
Nausea, dry mouth, somnolence, fatigue
Milnacipran (SNRI)
Start 12.5mg/d, increase to 50mg BID
Decrease pain, increase fibromyalgia ratings vs placebo
Nausea, HA, dizziness, palpitations
Gabapentin
Start 100mg QHS, increase to 600mg TID
Decrease pain, less evidence vs pregabalin
Sedation, dizziness, lightheadedness, increase wt
