What you can do for your fibromyalgia patient
ABSTRACT
Patients with fibromyalgia typically have pain “all over,” tender points, generalized weakness and fatigue, nonrestorative sleep, and a plethora of other symptoms. In contrast to inflammatory and autoimmune conditions, laboratory tests and physical examination findings are usually normal. American College of Rheumatology guidelines facilitate diagnosis. Management requires a multifaceted, long-term strategy that emphasizes improving function rather than reducing pain.
KEY POINTS
- Fibromyalgia is a clinical diagnosis, and specialized testing beyond basic laboratory tests is not indicated.
- Antinuclear antibody test results can be confusing, and the test should not be ordered unless a patient has objective features suggesting systemic lupus erythematosus.
- Treatment should be tailored to comorbidities such as depression, anxiety, and sleep disturbance. Options include serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), selective serotonin reuptake inhibitors, low-dose tricyclic antidepressants (eg, amitriptyline), and gabapentinoids (pregabalin or gabapentin). These drugs can be used singly or in combination.
- Medications that do not work should be discontinued.
- “Catastrophizing” by the patient is common in fibromyalgia and can be addressed by education, cognitive behavioral therapy, and anxiolytic or antidepressant drugs.
- Sustained, lifelong exercise is the treatment strategy most associated with improvement.
Exercise improves symptoms
Exercise improves fibromyalgia on many fronts and is associated with a host of positive effects in the brain and peripheral muscles. Exercise improves Fibromyalgia Impact Questionnaire scores, increases physical function and fitness, and reduces tender point counts, depression, and catastrophizing.41–52 There is no consensus on the best type of exercise, but both strengthening and aerobic exercises appear to be important.
I tell patients that fibromyalgia is an exercise-deprivation syndrome. Many are afraid to exercise because they associate it with pain and exhaustion afterwards. Patients should be encouraged to start with something very low-impact, such as gentle exercise in a warm-water pool. It should be emphasized that exercise is a lifelong treatment.
Drug therapy
The US Food and Drug Administration has approved 3 drugs for fibromyalgia management: 2 serotonin-norepinephrine reuptake inhibitors (duloxetine and milnacipran) and 1 gabapentinoid (pregabalin). Our patient in Case 2 is taking 2 of them without apparent benefit and has previously had no success with the third. This is not surprising. A summary of published treatment research on these drugs found that only 50% to 60% of patients tested reported more than 30% pain reduction.53 The studies also showed a placebo response of 30% to 40%. Depending on the study, the number needed to treat to see a benefit from these drugs is 8 to 14.53
EVALUATING THE SEVERITY OF FIBROMYALGIA
Focusing on key characteristics of the patient’s history can help evaluate fibromyalgia and determine a treatment strategy (Table 3). The Fibromyalgia Impact Questionnaire is also a useful evaluation tool.
It is important to assess the severity of fibromyalgia because patients with severe fibromyalgia are not good candidates for further referral to other specialists. They instead need chronic rehabilitation services, where they can learn to better function with a chronic pain syndrome.
In general, patients with the following features have conditions with high severity:
Symptoms: High burden and intensity
Function: Disabled, unemployed, interference with activities of daily living
Mood: Severe depression, bipolar disorder, axis II disorder, posttraumatic stress disorder
Medications: Polypharmacy, opioid drugs, multiple failed interventions
Maladaptive attitudes: High catastrophizing, refusal to accept diagnosis
Fibromyalgia Impact Questionnaire score: 60 or above.
The fibromyalgia of our patient in Case 2 would be categorized as severe.
MULTIFACETED MANAGEMENT
Patients with fibromyalgia are a heterogeneous group, and the syndrome does not lend itself to a single management strategy.54 Multiple guidelines have been published for managing fibromyalgia.55–57 Thieme et al58 reviewed existing guidelines and the strength of their recommendations. The guidelines unanimously strongly favor exercise, and most also strongly favor cognitive behavioral therapy. Most favor treating with amitriptyline and duloxetine; recommendations for other antidepressants vary. Nonsteroidal anti-inflammatory drugs, opioid drugs, and benzodiazepines are not recommended.
We offer a monthly 1-day clinic for patients and family members to provide education about fibromyalgia, discuss the importance of exercise, counsel on maladaptive responses, and demonstrate mindfulness techniques. We focus on function rather than pain. Interactive online-based interventions using cognitive behavioral techniques, such as FibroGuide: A Symptom Management Program for People Living With Fibromyalgia, developed at the University of Michigan, have proven helpful.59
RECOMMENDATIONS
For most patients, do not focus on pain reduction, as that is ineffective. Instead, target reversible factors, eg, mood, sleep, exercise status, stressors, and maladaptive attitudes toward pain. Possible treatment combinations include:
- A serotonin and norepinephrine reuptake inhibitor (eg, duloxetine)
- A low-dose tricyclic antidepressant at bedtime (eg, amitriptyline)
- A gabapentinoid (pregabalin or gabapentin).
If a medication within a class does not work, stop it and try another rather than add on.
Treat mild to moderate fibromyalgia with multidisciplinary interventions, with or without centrally acting medications. Treat severe fibromyalgia with more intensive psychiatric or psychologic interventions, multidisciplinary care, and medications targeted at comorbidities. Provide all patients with education and advice on exercise.
Keep laboratory tests and imaging studies to a minimum: a complete blood cell count with differential, comprehensive metabolic panel, thyroid-stimulating hormone, C-reactive protein, and Westergren sedimentation rate. Do not test for ANA unless the patient has objective features suggesting SLE.
