Fibromyalgia Syndrome

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Fibromyalgia Syndrome
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• Sarah McGrew, BSN
• OU-COM Social Medicine
• 333 Grosvenor Hall
• mcgrew_at_ohio.edu

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Objectives
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• Define Fibromyalgia Syndrome (FMS)
• Identify biochemical factors
• Review SOAP process
• Discuss pharmacological and non-drug treatment

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What is FMS?
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• FMS is a a group of symptoms which together
  indicate a disease or condition
• Unexplained condition
• No consistent tissue or laboratory abnormality

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Common Symptoms
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• Widespread body pain for 3 mos.
• Morning stiffness and fatigue
• Headaches
• Sleep disturbance
• Depression and anxiety
• Cognitive dysfunction
• Irritable bowel and bladder
• Paresthesias

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What Causes FMS symptoms?
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• Central Sensitization
• Disturbed components of the stress response
  system
• Dysfunction of the HPA axis
• Neurochemical abnormalities
• that results in
• allodynia (pain from stimuli that would not feel
  painful to others)
• hyperalgesia (lower pain thresholds and inability
  to tolerate pain for as long)

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Overlapping Conditions
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• Chronic Fatigue Syndrome
• Allergies
• Irritable bowel/bladder syndromes
• TMJ dysfunction
• Periodic Limb Movement Disorder (Restless Leg
  Syndrome)
• Autoimmune diseases such as RA and SLE

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Subjective Assessment
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• Hx of chief complaint
• Past Medical Hx
• Medication Hx
• Family Hx
• Psychosocial

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Objective Assessment
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• Physical exam
• Diagnostic criteria

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Fibromylagia Impact Questionnaire
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• http//www.myalgia.com/FIQ/fiq.pdf

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Differential diagnoses
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• Chronic fatigue syndrome
• RA
• Sjogrens syndrome

• SLE
• AS
• PMR
• Myositis

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Ddx (contd)

• Metabolic myopathies
• Hypothyroidism
• Hyperparathyroidism
• Cushings syndrome

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Diagnostic procedures
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• CMP
• CBC
• TSH
• T3, T4
• ESR

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Diagnostic tests (contd)

• liver panel
• creatinine phosphokinase
• depression scale
• sleep analysis

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Treatment of FMS
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• Multi-dimensional treatment yields optimum
  results
• Drugs
• Sleep Aids
• Antidepressants
• Analgesics
• Other

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Goals of Drug Treatment
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• Adequate sleep
• Reduce fatigue and depression
• Treat muscle spasms
• Pain control

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Sleep Aids
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• Tricyclic Antidepressants
• Amitriptyline (Elavil)
• increase circulating norepinephrine and serotonin
• start at very low doses 2 3 hours before
  bedtime and increase gradually
• SE blurred vision, dry mouth, orthostatic
  hypotension, diaphoreses, weight gain

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Sleep Aids (contd)
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• Muscle relaxants
• Cyclobenzaprine (Flexeril)
• start at 10 mg one hour before bed may
  increase to 40 mg gradually
• SE drowsiness, dizziness, dry mouth, irregular
  pulse

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Sleep Aids (contd)
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• Antihistamine
• diphenhydramine (Benadryl)
• prevents initiation and transmission of nerve
  impulses
• 50 mg ½ to 1 hour before bed.
• SE drowsiness, sedation, dizziness, seizures,
  thickening of secretions

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Sleep Aids
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• Benzodiazepines
• E.g. alprazolam (Xanax)
• promotes inhibitory neurotransmitters but may
  interfere with restorative sleep
• SE drowsiness, lightheadedness, depression, dry
  mouth, constipation.

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Antidepressants
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• Selective Serotonin Reuptake Inhibitors (SSRIs)
• E.g. Fluoxetine (Prosac)
• Act by limiting the reuptake of serotonin
• SE HA, somnolence, dizziness, nervousness,
  insomnia, constipation, dry mouth and sexual side
  effects

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Antidepressants (contd)
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• Serotonin Norepinephrine Reuptake Inhibitors
  (SNRIs)
• Effexor, Cymbalta, Serzone
• Act by limiting the reuptake of both
  norepinephrine and serotonin

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Antidepressants (contd)
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• Norepinephrine Serotonin Reuptake Inhibitors
  (NSRIs)
• Milnacipran
• Prefers reuptake of NE over serotonin
• similar pharmacologic profile to tricyclic
  antidepressants without the SEs
• Recruiting for clinical trials

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Analgesics
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• NSAIDs not usually helpful
• Analgesics
• tramadol (Ultram) 50 100 mg Q4-6 hrs most
  effective in controlled trials
• tramadol/acetaminophen (Ultracet) may be helpful
  when pain cannot be managed by Ultram or Tylenol
• Narcotics not usually recommended

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Other Drugs
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• Anticonvulsants
• Pregabalin (Lyrica)
• more potent version (and successor to Neurontin)
• for neuropathic pain, generalized anxiety
  disorder
• also used for panic disorder, single drug
  treatment for epilepsy

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Combination Treatment
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• A combination of medications, eg. a tricyclic at
  bedtime, SSRI during the day, with an analgesic
  of some sort PRN is found by most patients to be
  more effective than one-drug therapy
• Needs to have non-drug treatment added as well
• Need to treat overlapping conditions

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Treatment (contd)

• Non-drug
• Education
• Support
• Exercise
• Sleep
• Managing fatigue
• Controlling emotions/stress

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Patient and Family Education
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• Validate the diagnosis
• Educate about
• Prognosis
• Pathophysiology
• Treatment principles

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Non-Drug Treatment
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• Exercise
• Cardiovascular
• Muscle stretching/strengthening
• Massage
• OMM
• Acupuncture
• Controlling emotions/stress

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Resources
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• National Center for CAM (www.nccam.nih.gov)
• Arthritis Foundation (www.arthritis.org)
• National Fibromyalgia Association
  (http//fmaware.org)
• National Institutes of Health (http//www.nih.gov)
  

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More Resources
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• FIQ http//www.myalgia.com/FIQ/fiq.pdf
• Desmeules, JA, Cedrascjo C., Rapiti E.
  Neurophysiologic evidence for a central
  sensitization in patients with FM. Arthritis and
  Rheumatism 2003481420-1429.
• Martin David P. et al. "Improvement in
  fibromyalgia symptoms with acupuncture results
  of a randomized controlled trial." Mayo Clinic
  Proceedings. 81.6 (2006)749-57.

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Reference
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• Fibromyalgia Treatment Guidelines
  http//www.guideline.gov/summary/word.aspx?doc_id
  7352stat1string