Fibromyalgia and Trigeminal Neuralgia

Question 1

Treatment for fibromyalgia

Answer 1

Amitriptyline + Cyclobenzaprine

Low dose amitriptyline in combination with either duloxetine or gabapentin/pregabalin

Exercise program, mediative movement (yoga), acupuncture, psychiatric treatment, pain center.
Education regarding the disease and expectations for treatment is important

Question 2

Amitriptyline - Dose and route

Answer 2

10-30 mg x 1 orally

Question 3

Duloxetine - Dose and route

Answer 3

60 mg x 1 orally

Question 4

Duloxetine - MoA

Answer 4

Serotonin-norepinephrine reuptake inhibitor

Question 5

Duloxetine - Adverse effects

Answer 5

Nervousness
Dizziness
Insomnia

Question 6

Duloxetine - Contraindications

Answer 6

Use with MAOIs
Patients with Renal failure
Uncontrolled narrow-angle glaucoma

Question 7

Duloxetine - Interactions

Answer 7

Serotonin syndrome with MAOIs

Question 8

Treatment for Trigeminal neuralgia

Answer 8

Carbamazepine is first line. Alternatives are oxcarbazepine lamotrigine and phenytoin.

Surgical therapy such as microvascular decompression is very effective.

Question 9

Carbamazepine - Dose and route

Answer 9

100mg x 1 orally

Increase the dose gradually (by 100 mg daily in divided doses every 1-2 days) until substantial (>50%) pain relief is achieved.

Question 10

Carbamazepine - MoA

Answer 10

Block voltage sensitive Na+ channels

Question 11

Carbamazepine - Adverse effects

Answer 11

Drowziness
Ataxia
GI reactions (Nausea)
Aplastic Anemia (Rare)
Litium toxicity

Question 12

Carbamazepine - Contraindications

Answer 12

Hypersensitivity

Question 13

Carbamazepine - Interactions

Answer 13

Induce cytochrome P450 enzymes and accelerates metabolism of lamotrigine, phenytoin, topiramate and valproate.sensitivity

Question 14

Lamotrigine - Dose and route

Answer 14

400mg x 1 orally

Question 15

Lamotrigine - MoA

Answer 15

Block voltage-sensitive Na2+ channels

Question 16

Lamotrigine - Adverse effects

Answer 16

Cerebellar dysfunction
Drowsiness
Rash that can progress to Stevens-Johnson syndrome
Aseptic meningitis

Question 17

Lamotrigine - Contraindications

Answer 17

Hypersensitivity, use cautiously in patient taking valproate or have hepatic or liver disease

Question 18

Lamotrigine - Interactions

Answer 18

Serum levels are decreased by carbamazepine and phenytoin and increased by valproate

Question 19

Fibromyagia - Diagnosis

Answer 19

Pain should have been present most of the day on most days for at least 3 months
Criteria:
1) Widespread pain index >or equal to 7, Symptom severity > or equal to 5 or WPI of 3-6 and SS > or equal to 9
2) Symptoms manifest at a similar level for at least 3 months
3) Exclusion of other explanation for the pain

Question 20

Fibromyalgia - Differential diagnosis

Answer 20

Osteoarhritis, RA, SLE, Sjögren, MS, Hep C, Lyme

Question 21

Trigeminal Neuralgia - Diagnosis

Answer 21

Description of the pain:
- Sudden, shock-like and brief
- Location
- Triggers
Neurologic exam: branches of trigeminal nerve, reflexes
MRI: determine if MS or a tumor is the cause. Vascular compression of trigeminal nerve.
MR angiogram:

Question 22

Cyclobenzaprine - Dose

Answer 22

10-30 mg PO