SANTA MONICA, CALIF. — Effective treatments exist for fibromyalgia syndrome, but many physicians still do a poor job of treating affected patients, according to Dr. Chad S. Boomershine.

Could it be that these physicians don't consider fibromyalgia to be a “real” disease, that they perceive affected patients as being too time consuming and unlikely to get better? asked Dr. Boomershine, a rheumatologist at Vanderbilt University in Nashville, Tenn., where he specializes in treating fibromyalgia in collaboration with the Vanderbilt Center for Integrative Health and the Vanderbilt Dayani Center.

About 2%-4% of the U.S. population meet the fibromyalgia classification criteria issued in 1990 by the American College of Rheumatology. The true prevalence is estimated to be about twice as high.

The ACR classification criteria for fibromyalgia include widespread pain for at least 3 months' duration, and pain at a minimum of 11 of 18 specified tender points when enough pressure to just blanch the examiner's thumbnail is applied. The reported 9:1 ratio of women to men with the condition is incorrect, he said, as women have more tender points and men are more likely to self-medicate rather than to seek medical care.

Fibromyalgia typically involves symptoms other than pain, which Dr. Boomershine teaches using the FIBRO mnemonic (F for fatigue and 'fibrofog' [cognitive dysfunction], I for insomnia [nonrestorative sleep], B for blues [depression and anxiety], R for rigidity [muscle and joint stiffness], and O for Ow! [pain and work disability]). Nevertheless, pharmacologic management should start by treating pain because it is the one symptom common to all fibromyalgia patients, he said. When choosing among the three indicated medications, individualize therapy based on the associated symptom that is most disabling for the patient, Dr. Boomershine said at a meeting sponsored by

Pain associated with insomnia is best treated with pregabalin (Lyrica), he said. The label states that pregabalin should be given in two divided doses daily beginning with a total of 150 mg/day and increasing to as much as 450 mg/day if needed. In an effort to avoid the typical side effects of dizziness, somnolence, fatigue, and cognitive dysfunction, however, Dr. Boomershine recommends beginning with 25-75 mg once daily at bedtime and titrating up to 150-225 mg at night before adding a morning dose.

Pain with depression and/or anxiety is best managed with duloxetine (Cymbalta) every morning, he said. The label states that the recommended dosage for fibromyalgia is 60 mg/day, but Dr. Boomershine recommends starting with 20-30 mg and increasing to 60 mg only if necessary. Trial data indicate that many patients do well on lower doses, he noted, and higher doses are associated with increased risk for side effects.

For pain associated with fatigue, the treatment of choice is milnacipran (Savella), he said. The label for this agent recommends starting at a dose of 12.5 mg once daily and gradually working up to 50 mg twice daily after 1 week and a maximum dosage of 100 mg twice daily. But Dr. Boomershine recommends titrating the dosage up more gradually.

Dr. Boomershine is an investigator for Pfizer Inc. and the National Institutes of Health, and is a consultant for Pfizer, Eli Lilly & Co., Forest Pharmaceuticals Inc., and Takeda Pharmaceutical Co.

SDEF and this news organization are owned by Elsevier.

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Management should start by treating pain because it is the one symptom common to all patients.

Source DR. BOOMERSHINE

Advise Patients To Get Moving

Although effective medications are available, it takes more than drug therapy to manage fibromyalgia, according to Dr. Chad S. Boomershine.

“I recommend patients perform stretches every morning and, on alternating days, engage in aerobic and resistance exercise a total of 6 days per week,” he said.

“The combination of aerobic and resistance exercise is particularly effective in improving symptoms. Since many patients don't live near an exercise facility, I provide patients with instructional handouts and [professional elastic resistance bands] for resistance exercise on their initial visit so they can exercise at home,” the rheumatologist from Vanderbilt University added.

Dr. Boomershine said he refers his patients to the exercise guide on the National Institute on Aging Web site (

www.nia.nih.gov/Health Information/Publications/Exercise Guide

He also recommends the National Center on Physical Activity and Disability Web site for access to an exercise fact sheet that's helpful for younger patients (

www.ncpad.org/exercise/fact_sheet.php?sheet=259

Additionally, he recommends that patients learn more about fibromyalgia and find support groups in their area.

“Due to the severity of their symptoms, patients are often afraid they have a terminal illness,” he noted. “Understanding that fibromyalgia is not progressive and realizing they can manage their symptoms by learning self-help techniques is empowering and necessary if patients are to have lasting symptom improvement.”

The Web sites

www.knowfibro.com

www.fmaware.org

Fibromyalgia Undertreated, Despite Therapies