Transcript of “I Hurt Everywhere” “I Hurt Everywhere” Beginning the Fibromyalgia (FM) Journey? Steven S....
- Slide 1
- I Hurt Everywhere I Hurt Everywhere Beginning the Fibromyalgia
(FM) Journey? Steven S. Overman MD MPH Medical Director, Northwest
Hospital Rheumatology and Musculoskeletal Development Rheumatology
and Musculoskeletal Development Clinical Associate Professor of
Medicine University of Washington University of Washington
- Slide 2
- Chronic Widespread Pain (CWP) Prevalence: 10 13% of western
populationsPrevalence: 10 13% of western populations Incidence:
5.5%/year of new cases of CWPIncidence: 5.5%/year of new cases of
CWP 2% in persons without any pain 8% in persons with chronic
regional pain Outcomes: at one year of CWP personsOutcomes: at one
year of CWP persons 56% still had CWP (more somatic symptoms
increased likelihood) 33% had regional pain 11% had no pain Croft J
of MS Pain 2002;10:191-199
- Slide 3
- Predictors of CWP 2x prevalence in women ( FM is 4x )2x
prevalence in women ( FM is 4x ) Persons with CWP more commonly
have -Persons with CWP more commonly have - Anxiety and depression
Fatigue and other somatic complaints Anxieties about health
Features of somatization Dissatisfaction with health care and work
Absolute differences not largeAbsolute differences not large
Psychiatric diagnoses 16.9% in CWP vs 11.9% pop Croft J of MS Pain
2002;10:191-199
- Slide 4
- Relevance of CWP and Tender Points (TPs) 40% of CWP have FM
(> 11 TPs)40% of CWP have FM (> 11 TPs) Some patients with no
pain (5%) and regional pain (20%) had > 11 TPsSome patients with
no pain (5%) and regional pain (20%) had > 11 TPs Local TPs
associate with segmental painLocal TPs associate with segmental
pain Depression, fatigue and sleep disorders increased as TPs rose,
independent of pain complaints.Depression, fatigue and sleep
disorders increased as TPs rose, independent of pain complaints.
Thomas BMJ 1999:318: 1662-7 Croft BMJ 1994; 309: 696-9
- Slide 5
- FM is a Syndrome of Pain and Tenderness ACR Classification -
1990 Pain for 3 monthsPain for 3 months Generalized pain at least 3
quadrantsGeneralized pain at least 3 quadrants At least 11 out of
18 tender points painful with 4 kg of pressureAt least 11 out of 18
tender points painful with 4 kg of
pressure------------------------------------------- FM is at the
severe end of a spectrum of pain and tenderness disordersFM is at
the severe end of a spectrum of pain and tenderness disorders Not a
diagnosis of exclusion.Not a diagnosis of exclusion. FM tenderness
is not limited to the 18 points.FM tenderness is not limited to the
18 points. Many feel multi-system symptoms should be present to
diagnose FM.Many feel multi-system symptoms should be present to
diagnose FM.
- Slide 6
- Multi-system Symptoms Found in > 50% of FM patients from the
ACR 1990 Criteria for Classification Study Neck pain85%Neck pain85%
Back pain79%Back pain79% Fatigue78%Fatigue78% Sleep
disturbance76%Sleep disturbance76% Morning stiffness76%Morning
stiffness76% Paresthesias67%Paresthesias67% Skin fold tender,
trapezius60%Skin fold tender, trapezius60% Headaches54%Headaches54%
Wolfe A&R 1990; 33: 160-172
- Slide 7
- Multi-system Symptoms Found in < 50% of ACR FM Study
patients Anxiety 45%Anxiety 45% Sicca or dry eye symptoms36%Sicca
or dry eye symptoms36% Prior depression31%Prior depression31%
Irritable bowel syndrome30%Irritable bowel syndrome30% Urinary
urgency26%Urinary urgency26% Raynauds phenomenon 17%Raynauds
phenomenon 17%
- Slide 8
- Syndromes That Overlap With Fibromyalgia The neurologist sees
chronic headache, the gastroenterologist sees IBS, the
otolaryngologist sees TMJ syndrome, the cardiologist sees
costochondritis, the rheumatologist sees fibromyalgia, and the
gynecologist sees PMS.
- Slide 9
- Objectives To define Fibromyalgia (FM) and discuss FM as a
patient labelTo define Fibromyalgia (FM) and discuss FM as a
patient label Discuss the medical evaluation of FM in relationship
to pathophysiologic insightsDiscuss the medical evaluation of FM in
relationship to pathophysiologic insights Review evidence that can
guide individual treatment decisions for patients with FMReview
evidence that can guide individual treatment decisions for patients
with FM
- Slide 10
- Disclosures I have no pharmaceutical grants or consulting for
any FM medication.I have no pharmaceutical grants or consulting for
any FM medication. I am not an Expert, just a Rheumatologist.I am
not an Expert, just a Rheumatologist. A successfully trained
rheumatologist is someone who can look patients in the eye all day
long and say I dont know. I am not recruiting more FM patients, but
I have not closed my practice either.I am not recruiting more FM
patients, but I have not closed my practice either.
- Slide 11
- Definition Fibromyalgia syndrome is a chronic pain disorder
with widespread tenderness. It is commonly associated with symptoms
common to the affective spectrum disorders. Dysregulation is found
in the nervous, immune and adrenal stress systems. A combination of
bio-psycho- social factors contribute to FMS pathophysiology and
influence outcomes.
- Slide 12
- Liz 40 year-old Caucasian woman with neck, back and generalized
pain. Liz is an office manager and had been an avid water skier
until 2 yrs. ago when she fell very hard water skiing, twisting her
neck, and laying her up for several weeks. She actually never
recovered noting episodes of low back pain, fatigue and increased
difficulty sleeping. She started having panic episodes 1 year agon
which were initially controlled with Paxil. Work is more and more
difficult due to fatigue and problems with concentration. Screening
Exam 14/18 tender points are positive, worse around her neck and
shoulders.
- Slide 13
- #1 What do you say to Liz? 1.Tell her she has Fibromyalgia
disease, which has no cures and with varying impacts on different
individuals. Suggest a book or web site for her to learn about FM
and return prn. 2.Tell her she a generalized pain syndrome of
unclear etiology and that she will have to learn to live with it.
Offer a referral to your pain psychologist and come back in 2
months. 3.Describe your findings as consistent with Fibromylagia
syndrome and suggest further investigation and symptom
management.
- Slide 14
- Answer to #1 1.Tell her she has Fibromyalgia disease that no
cures and with varying impacts on different individuals. Suggest a
book or web site for her to learn about FM. 2.Tell her she a
generalized pain syndrome of unclear etiology and that she will
have to learn to live with it. Offer a referral to your pain
psychologist. 3.Describe your findings as consistent with
Fibromylagia syndrome and suggest further investigation and symptom
management.
- Slide 15
- Is Labeling someone with FM a BAD idea? It depends A population
study showed that providing the label Fibromyalgia did not result
in an increase prevalence, nor increase illness behavior.A
population study showed that providing the label Fibromyalgia did
not result in an increase prevalence, nor increase illness
behavior. (White A&R (AC&R), 2002;47:260-5) The FM
associated disability did not change after a claim or suit was
closed. (Moldofsky J Rheum 1993:20:1935-40)The FM associated
disability did not change after a claim or suit was closed.
(Moldofsky J Rheum 1993:20:1935-40) Labeling promotes
categorization for scientific evaluation, e.g. Lupus spectrum of
illnessLabeling promotes categorization for scientific evaluation,
e.g. Lupus spectrum of illness FM is not the cause, but rather the
result of a variety of interacting factors. Dr O
- Slide 16
- #2 What areas need to be considered for investigation? 1.Causes
of peripheral pain 2.Causes of nervous system sensitization
3.Disorders resulting from chronic distress 4.Risks for pain
associated disability 5.All of the above.
- Slide 17
- Answer to #2 ALL THE ABOVE Directed by further history and
exam, evaluate: Causes of peripheral painCauses of peripheral pain
Causes of nervous system sensitizationCauses of nervous system
sensitization Disorders resulting from chronic distressDisorders
resulting from chronic distress Risks for pain associated
disabilityRisks for pain associated disability
- Slide 18
- Neck Injury is associated with the development of FMS Israel
study showing 21.6% of neck injury patient developed FM compared to
1.7% of leg fracture patients. (Buskila A&R 2002;
4:450-3))Israel study showing 21.6% of neck injury patient
developed FM compared to 1.7% of leg fracture patients. (Buskila
A&R 2002; 4:450-3)) UW study Two months after whiplash injury,
80% had TPs of FM, while 20% also had widespread pain to meet FMS
classification criteria.UW study Two months after whiplash injury,
80% had TPs of FM, while 20% also had widespread pain to meet FMS
classification criteria. (Robinson, World Conference on Pain,
2003)
- Slide 19
- The Over-diagnosis of FM Syndrome 321 new rheumatology
referrals321 new rheumatology referrals 35 (11%) were diagnosed
with FM35 (11%) were diagnosed with FM 11 (~ 34% of all FM
patients) were newly diagnosed with a spondyloarthropathy MA
Fitzcharles, Am J Med, 1997;103:44-50
- Slide 20
- Enthesiopathies Disease Association: Spondyloarthritis, Reiters
syndrome, Reactive arthritis, Psoriasis arthritis, Crohns and
Celiac associated arthritisDisease Association: Spondyloarthritis,
Reiters syndrome, Reactive arthritis, Psoriasis arthritis, Crohns
and Celiac associated arthritis Anatomic Locations: epicondylitis,
rotator cuff capsulitis, dactylitis, trochanteric tendinitis,
ilio-lumbar ligament itis, plantar fasciitis, Achilles tendinitis
and SI joint, AC and costochondral joints, facet and ribs
articulationsAnatomic Locations: epicondylitis, rotator cuff
capsulitis, dactylitis, trochanteric tendinitis, ilio-lumbar
ligament itis, plantar fasciitis, Achilles tendinitis and SI joint,
AC and costochondral joints, facet and ribs articulations
- Slide 21
- Pain Response in Fibromyalgia RELATIVE PAIN
- Slide 22
- What are Clinical features of Nervous System Sensitization?
Abnormal Wind-up repetitive stimulation with identical stimuli
cause progressive increase in pain intensity.Abnormal Wind-up
repetitive stimulation with identical stimuli cause progressive
increase in pain intensity. FM patients this lasts longer (up to 2
minutes) and with more burning, stinging, and sometimes numbness,
than controls Central sensitization refers to the changes that
occur in the nervous system (neuroplasticity). High stimulus
frequency and intensity AND reduced descending pain inhibition from
the brain lead to permanent wind-up through gene transcription
changes.Central sensitization refers to the changes that occur in
the nervous system (neuroplasticity). High stimulus frequency and
intensity AND reduced descending pain inhibition from the brain
lead to permanent wind-up through gene transcription changes. The
same stimulus registers at a much greater intensity when compared
to a normal person.
- Slide 23
- Evidence of Nervous System Sensitization in FM In FM patients
compared to controls: Functional MRI has shown enhanced sensory
receptive areas and expanded fields of reception to the same pain
stimulus.Functional MRI has shown enhanced sensory receptive areas
and expanded fields of reception to the same pain stimulus. (Cook J
Rheum 2004;31:364-78) Laser-evoked potentials in the CNS have
demonstrated increased amplitudes proportional to the subjective
response to skin stimulation.Laser-evoked potentials in the CNS
have demonstrated increased amplitudes proportional to the
subjective response to skin stimulation. (Gibson Pain
1994;58:185-93)
- Slide 24
- Peripheral Sensitization in Fibromyalgia Syndrome Trigger
Points (TPs) correlate with levels of CSF substance PTrigger Points
(TPs) correlate with levels of CSF substance P Epidural blocks
remove pain and tenderness of TPsEpidural blocks remove pain and
tenderness of TPs (Bengtsson Pain 1989; 39:171-180)
- Slide 25
- Triggers of Central Sensitization Cytokines Il-1 and IL-6
induces hyperalgesia IL-8 promotes sympathetic pain TNF alpha
stimulates macrophages and microglia cells which sensitize neurons
Elevation found in cases of FM cases less than 2 years
duration.Elevation found in cases of FM cases less than 2 years
duration. Cytokines maybe stimulated by stress, injury or
inflammatory diseases.Cytokines maybe stimulated by stress, injury
or inflammatory diseases. (Wallace Rheum 2001;40:743-749)
- Slide 26
- Triggers Central Pain Sensitization Functional polymorphism in
the promoter region of the serotonin transporter geneFunctional
polymorphism in the promoter region of the serotonin transporter
gene Smokers have have higher levels of substance P in the
CSF.Smokers have have higher levels of substance P in the CSF.
Patients with Restless Leg Syndrome have increased hyperalgesia
that resolves with treatment.Patients with Restless Leg Syndrome
have increased hyperalgesia that resolves with treatment.
- Slide 27
- Modulators of Sensitization CSF pain modulators affected by
wind-upCSF pain modulators affected by wind-up NMDA receptors help
induce sensitization. After IV infusion Ketamine, an NMDA blocker,
FM patients noted pain reduction and improved muscle endurance for
2-7. (Sorensen Scand J Rheum 1995; 24: 360-365) Substance P are 3-4
times increased in spinal fluid Serum and platelet serotonin levels
are reduced in FM patients. (Wolfe J Rheum 1997; 24:555-9 )
- Slide 28
- Disorders of Distress Chronic stress causes initial increase of
corticotropin releasing factor (CRF). This may lead to reduction in
CRF-1 receptors and a reduction of ACTH and the cortisol response.
CRF increases somatostatin causing a reduction in GH
secretion.Chronic stress causes initial increase of corticotropin
releasing factor (CRF). This may lead to reduction in CRF-1
receptors and a reduction of ACTH and the cortisol response. CRF
increases somatostatin causing a reduction in GH secretion.
- Slide 29
- Disorders of Distress Sleep dysregulation may induce reduced
growth hormone secretion and lower IGF-1 levels. Tender points
develop for unclear reasons.Sleep dysregulation may induce reduced
growth hormone secretion and lower IGF-1 levels. Tender points
develop for unclear reasons. Other conditions with impaired
cortisol secretion: chronic pelvic pain, Chronic fatigue, PTSD,
overtraining syndromeOther conditions with impaired cortisol
secretion: chronic pelvic pain, Chronic fatigue, PTSD, overtraining
syndrome
- Slide 30
- What are Predictors of Disability? PTSD like symptoms
hyper-vigilance, catastrophizing, low self-efficacy, harm
avoidance, active coping (56%)PTSD like symptoms hyper-vigilance,
catastrophizing, low self-efficacy, harm avoidance, active coping
(56%) Limited exerciseLimited exercise Physical Function at
presentationPhysical Function at presentation Depression, anxiety
psychologic distressDepression, anxiety psychologic distress
Pending litigationPending litigation Level of educationLevel of
education
- Slide 31
- #3 Is FM primarily a Psychiatric Disorder? 1.YES It shares
similar pathophysiology as the anxiety-depression spectrum of
disorders. 2.NO FM is like other diseases that are made worse by or
lead to stress-depression. 3.MAYBE There are studies that suggest
FM is in the group of affective spectrum disorders.
- Slide 32
- #3 Primarily a Psychiatric Disorder? 1.YES It shares similar
pathophysiology as the anxiety- depression spectrum of disorders.
2.NO FM is like other diseases that are made worse by or lead to
stress- depression. BUT Stress factors may be necessary
perpetuators to develop the full FM syndrome of pain, tenderness
and somatic symptoms.
- Slide 33
- Psych Literature and FM FM non-patients had no greater number
of psych diagnoses than population controlsFM non-patients had no
greater number of psych diagnoses than population controls Past
& current depressive disorders higherPast & current
depressive disorders higher 20% of FM persons who seek any care 90%
of FM patients at UW university rheum clinic had a past history of
psychiatric diagnoses
- Slide 34
- Melzacks Neuromatrix Endocrine, immune, and autonomic system
activity Afferent input Medullary descending inhibition Pathologic
Input Central Nervous System Plasticity Attention Pain Perception
Pain Behavior Psychosocial and health status factors Neuromatrix
Brain areas that underlie pain experience and behavior Melzak, Pain
1999, 82 (supplement 6): S121-126
- Slide 35
- What is the Menu of Evaluations? Spine disordersSpine disorders
Inflammatory disordersInflammatory disorders Infectious
disordersInfectious disorders Psych disordersPsych disorders Sleep
dysfunctionSleep dysfunction Endocrine dysfunctionEndocrine
dysfunction Autonomic dysfunctionAutonomic dysfunction
- Slide 36
- Evaluation of Peripheral Pain Generators Neck, back, pelvis
painNeck, back, pelvis pain Entheseopathy or sacroiilits routine
x-rays Degenerative disc or facets routine x-rays Chiari or
cervical stenosis MRI if long-tract findings Spinal stenosis or
radiculopathy MRI Myofascial trigger point evaluation Ligaments,
etc. injection blockade
- Slide 37
- Evaluation of Peripheral and Central Pain Generators and
Sensitizers Inflammatory disordersInflammatory disorders
GeneralCRP, ESR, U/A BowelEndomesial (tTG) & Gliaden Abs, ASCA
ArthralgiasANA, ENA, RF, ACE SiccaSchirmers test, thyoid
antibodies, ANA, ENA Raynauds? cryoglobulins, Phospholipid Ab
screen, ANCA, nail fold eval., complements Infection
disordersInfection disorders Pelvic symptomsProstatitis, PID,
endometriosis, sacroiilitis (xray) Pharyngitis ASO titer, strept
screen Hep C riskHep C antibody (Sjogrens syndrome presentation)
HIV riskHIV screen (multiple rheumatic presentations) Lyme riskLyme
ELISA
- Slide 38
- MANY conditions can present with as FMS RA - 14 - 54% of
patientsRA - 14 - 54% of patients Lupus - 22 65% of patientsLupus -
22 65% of patients Sjogrens Syndrome - 47%Sjogrens Syndrome - 47%
Hep C - 16-18% (3x controls)Hep C - 16-18% (3x controls) HIV - 29%
of patientsHIV - 29% of patients Crohns disease - 49% of patients
attending a university clinic in Israel but no difference in
Norwegian population sample.Crohns disease - 49% of patients
attending a university clinic in Israel but no difference in
Norwegian population sample.
- Slide 39
- Evaluation of Central Pain Sensitizers and Behavioral
Amplifiers Psych screen and concernsPsych screen and concerns All
rheum new patients Screening questionnaires (depression, anxiety,
panic, stressful events, past trauma or abuse, alcohol screen,
function, pain, fatigue, sleep) FM patients Screen questionnaires
(ADD, PTSD, Bipolar, addiction risks, personality traits and coping
styles) Screen (+) patient and management problem Psychologist
referral and possible MMPI, etc. (poor compliance, yes, but ,
controlling, marital or job distress) SleepSleep Standard
questionnaires - apnea, restless legs, day-time sleepiness, fatigue
refer for sleep consult / study
- Slide 40
- Evaluation Distress Disorders and Secondary Dysfunctions
Endocrine evaluationEndocrine evaluation GeneralCBC, Full chemistry
Thyroid disorderTSH, antibodies Menopausal statusFSH HPA axis
(adrenal fatigue)AM cortisol Testosterone statusFree testosterone
Other muscle painDHEA-S, IGF-1, Mg, vit D Autonomic
DysfunctionAutonomic Dysfunction Postural hypotension or ^ HRTrial
of salt and stockings Tilt table test Tilt table test (Geenen Rheum
Dis Clinics May 2002)
- Slide 41
- FM Syndrome pain clearly depends on peripheral nociceptive
input as well as abnormal central pain processing.
- Slide 42
- Liz PMH: Divorced 8 years ago and remarried 3 years ago. Had an
abusive marriage. History of childhood non-sexual abuse
Intermittent pelvic pain since late teenager. Diagnosed with
hypothyroidism and started on treatment 6 months ago.
- Slide 43
- Liz ROS: Several years of night sweats and increasing fatigue
Morning stiffness in her feet without swelling Constipation and
energy are improved on thyroid Non-restorative sleep since her ski
injury Dry, gritty eyes
- Slide 44
- Liz Complete PE: Very tense, but engaging and personalVery
tense, but engaging and personal Skin no psoriatic pits, no
rashesSkin no psoriatic pits, no rashes Thyroid - slightly
enlargedThyroid - slightly enlarged CV/Pul/GI - negativeCV/Pul/GI -
negative MSK Peripheral joints negativeMSK Peripheral joints
negative SC and SI joints more tender than nearby tender points
Neck - reduced ROM; dorsal spines tender FM tenderness - 14/18
areas + others Neuro normal strength & sensation a; no clonus;
no reflex abnNeuro normal strength & sensation a; no clonus; no
reflex abn
- Slide 45
- #4 - What is the appropriate work- up for Liz? (1 or more)
1.CBC, Chem Screen, ESR, CRP, ANA TSH, FSH, pelvis x-ray,
psychologist referral 2.LP for substance P level in CSF 3.MRI
cervical spine and functional brain imaging 4.Sleep study 5.An
exercise growth hormone stimulation test
- Slide 46
- #4 - The appropriate work-up Step-wise Screening 1.CBC, Chem
Screen, ESR, CRP, ANA TSH, FSH, pelvis x-ray, psychologist referral
2.LP for substance P level in CSF 3.MRI cervical spine and
functional brain imaging 4.Sleep study 5.An exercise growth hormone
stimulation test
- Slide 47
- Lizs Evaluation Results X-ray mild SI sclerosis and tendon
calcificationsX-ray mild SI sclerosis and tendon calcifications
Labs CRP = Nl, ESR = 22, thyroid Abs (+), TSH 5.3Labs CRP = Nl, ESR
= 22, thyroid Abs (+), TSH 5.3 Other labs negativeOther labs
negative Psychologist notes significant family relationship
stressesPsychologist notes significant family relationship
stresses
- Slide 48
- What is in our bag of treatment tricks? CounselingCounseling
ExerciseExercise NutritionalNutritional SleepSleep Peripheral pain
rxPeripheral pain rx Central agentsCentral agents
EndocrineEndocrine
- Slide 49
- A Clinical Approach Patient centeredPatient centered Unique
clinical issues Negotiated illness model - to develop confidence in
program Understand personal values and goals Time awarenessTime
awareness Chronological assessment of illness factors, symptoms and
patients response to these issues Chronicity may lead to
irreversibility Rehabilitation ModelRehabilitation Model Positive,
hopeful, and can-do attitude Treat local impairments, monitor total
function, build on individual resources and social support to limit
handicap
- Slide 50
- Stuck Car Illness Model (ATime-dependent Psycho-biologic
Illness Model ) Pre-morbid Are underlying problems that will cause
FM or complicate recovery? Trigger events Are there recurrent
triggers? Perpetuating factors Are there patient behaviors that
will impair healing? Secondary conditions Are physiologic
dysfunctions that may be due to the illness experience?
- Slide 51
- Lizs Pre-morbid Conditions (You may have had thin tires before
you became stuck) Inflammatory - possible
spondyloarthopathyInflammatory - possible spondyloarthopathy Psyche
- past abusePsyche - past abuse Endocrine - hypothyroid, probable
autoimmuneEndocrine - hypothyroid, probable autoimmune
- Slide 52
- Lizs Triggering Events Neck injuryNeck injury Segmental
Inflammatory Acute stressAcute stress Family relations Pain
- Slide 53
- Lizs Perpetuating Factors Uncontrolled painUncontrolled pain
Increased worry, frustration, fatigue, depression Behaviors that
affect pain, sleep or the immune systemBehaviors that affect pain,
sleep or the immune system Reduced exercise Poor sleep hygiene Tire
spinning: Are you trying too hard or driving wrong for the
conditions?Tire spinning: Are you trying too hard or driving wrong
for the conditions? Low confidence in self-management Social
discord marriage or work
- Slide 54
- Associated Conditions to be Considered in Liz
DepressionDepression PTSD fear, angerPTSD fear, anger Sleep
apneaSleep apnea Cognitive dysfunctionCognitive dysfunction
FatigueFatigue
- Slide 55
- So What do we do for Liz? 1.Marital counseling 2.Stretching and
gentle aerobic exercise 3.Diclofenac, Tylenol and possibly
hydrocodone for arthritis/pain 4.Sulfasalazine for
spondyloarthritis 5.Switch paroxetine to venlafaxine 6.Short-term
work disability if needed
- Slide 56
- So What do we do for Liz? YES 1.Marital counseling 2.Stretching
and gentle aerobic exercise 3.Diclofenac, Tylenol and possibly
hydrocodone for arthritis/pain 4.Sulfasalazine for
spondyloarthritis 5.Switch paroxetine to venlafaxine 6.Short-term
work disability if needed
- Slide 57
- So What do we do for Liz? ALL Marital counselingMarital
counseling Stretching and gentle aerobic exerciseStretching and
gentle aerobic exercise Diclofenac, Tylenol and possibly
hydrocodone for arthritis/painDiclofenac, Tylenol and possibly
hydrocodone for arthritis/pain Sulfasalazine for
spondyloarthritisSulfasalazine for spondyloarthritis Switch
paroxetine to venlafaxineSwitch paroxetine to venlafaxine
Short-term work disability if neededShort-term work disability if
needed
- Slide 58
- Counseling Limited RCTs several show improved function for
cognitive-behavorial therapy plus exercise, focused on improving
functionLimited RCTs several show improved function for
cognitive-behavorial therapy plus exercise, focused on improving
function Bradley Curr Opin in Rheum 2002; 14:45-61 Turk, UW - 3
groups respond differently to CBT plus exerciseTurk, UW - 3 groups
respond differently to CBT plus exercise Dysfuncrtional responds
well Adaptive coper - minimal response Interpersonally distressed -
no response Turk
- Slide 59
- Exercise Aerobic program more effective than flexibility
exercise aloneAerobic program more effective than flexibility
exercise alone Pool exercise or deep water walking helpful for
those who cant walkPool exercise or deep water walking helpful for
those who cant walk Exercise programs more effective when a part of
a multi-disciplinary self-management programExercise programs more
effective when a part of a multi-disciplinary self-management
program Strength training can be effective additionStrength
training can be effective addition Self-treatment of trigger points
can be taughtSelf-treatment of trigger points can be taught
Individualized or group programs for FM patients improve retention
and effectivenessIndividualized or group programs for FM patients
improve retention and effectiveness
- Slide 60
- Nutrition and Supplements Limited studies suggesting Vegan diet
improves FM, but less than amitriptyline.Limited studies suggesting
Vegan diet improves FM, but less than amitriptyline.
Supplements:Supplements: Magnesium Malate 1200 mg / day showed
reduction in pain only in open label phase of a RCT NADH 10 mg /
day helped 30% in RCT Melatonin 3 mg HS showed improvement in
sleep, global and tenderness vs a control group Crofford Currnet
Rheum Reports I2001; 3:147156.
- Slide 61
- #5 - Which drugs are FDA approved for FMS treatment?
1.Amytirptyline 2.Fluoxetine 3.Zolpidem 4.Cyclobenzaprine 5.All of
the above 6.None of the above
- Slide 62
- SleepCLASSGENERICBRANDMECHANISM OF ACTION DOSE
TricylicantidepressntAmitriptylineDoxepinElavilSinequan 5-HT/NE RI
NMDA antagonist Cation channnel bl. 10 50 mg hs
SSRIFluoxetineSertalineProzacZoloft 5-HT re-up blocker 10 - 60 mg
am 25 200 mg hs Narcolepsy NA Oxybate Xyrem Alpha intrusions 3 gm
hs & 4hrs 2 nd genMAO Pirlindole(European) MAO A inh. Anti-
epileptics Pregabalin(coming soon) soon) Ca++ channel blocker 450
mg HypnoticsZopicloneZolpidemImovaneAmbien BZ recptor agonist 7.5
mg hs 5 10 mg hs MuscleRelaxantscyclobenzaprineFlexeril 5-HT 2
antag. Anti-chol/hista 5 -30 mg hs Rao Best Prac & Research
Clin Rheum 2003;17: 611-627
- Slide 63
- Peripheral Pain NSAIDs / COX IINSAIDs / COX II Number of
studies have not shown benefit in FM patients. Helpful for
peripheral pain generators May be important earlier in FM syndrome
OpioidsOpioids Morphine shown to not be helpful in FM 14% of FM
patients are on opioids, likely to help control peripheral pain
Topical agentsTopical agents
- Slide 64
- Central Pain CLASSGENERICBRANDMECHANISM OF ACTION DOSE
TricylicantidepressntAmitriptylineDoxepinElavilSinequan 5-HT/NE RI
NMDA antagonist Cation channnel bl. 10 50 mg hs Dual RI
VenlafaxineEffexor 5-HT>NE RI 375 mg / day*
SSRIFluoxetineSertalineProzacZoloft 5-HT re-up blocker 10 - 60 mg
am 25 200 mg hs 2 nd genMAO inhibitorPirlindole(European)Reversible
MAO A inh. Anti-epilepticsPregabalin(Gabapentin)NA(Neurontin) Ca++
channel blocker 450 mg 100 4000 mg
MuscleRelaxantscyclobenzaprineFlexeril 5-HT 2 antag.
Anti-chol/hista 5 -30 mg hs OpioidsTramadolUltram Mu; 5-HT,NE ri 25
100 mg qid AnestheicsKetamine NMDA antag IV
- Slide 65
- Endocrine Growth hormone deficiency?Growth hormone deficiency?
Symptoms: fatigue, dysphoria, impaired cognition reduced exercise
capacity, muscle weakness, cold intolerance. 30% of patients have
IGF-1 < 150 RCT of GH injections for 9 months 6 months in trail
15/22 experienced global improvement (p