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Fibromyalgia Case Discussion

Lyne,eCederquistM.D.ClinicalProfessorofMedicine

UniversityofCalifornia,SanDiego

Objectives

•  IdenDfychallengesofdiagnosingfibromyalgia•  DiscusspracDcalapproachestotheworkup•  Outlineastrategyformanagingfibromyalgia

Disclosure

•  Nothingtodisclose.

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61-year-old woman with gradual onset total body pain

•  Startedalmostayearago•  Achy,sDffmusclepainandachyjoints.Nojointswelling,nomuscleweakness.

ShefeelsherpainisworseaQerexercising,butdoesnotimprovesignificantlywithrest.

•  AccompaniedbyworseningfaDgueandpoorsleep.Shewakesupfeelingexhausted.

•  HersymptomsstartedduringaperiodofextremeaddedstressatherjobasamarkeDngrepresentaDvewhichrequiredextensivetravel

•  PMH:Hypertension,hypercholesterolemia,Irritablebowelsyndrome•  MedicaDons:lisinopril10mgdaily,atorvastaDn40mgdaily,Metamucildaily,

prnibuprofen

61-year-old woman with gradual onset total body pain

•  SocialHistory:Married,wasworkingfullDmeasamarkeDngrepresentaDveforasoQwarecompany.Quitworking3monthsagoduetoherworseningsymptoms.

•  FamilyHistory:NegaDve•  ReviewofSystems:–  General:Noweightloss,fevers–  posiDveforfeelingmoredepressedpastfewmonthsbecauseoffeelingpoorly,notbeingabletoworkorexercising,andcurbinghersocialacDviDesbecauseshedoesn’tfeelwell.

–  Intermi,entabdominalcrampingwithmostlyconsDpaDon–  Herhusbandreportsthatshesnores

What else would you want to know?

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What else would you want to know?

•  CurrentlevelofacDvityandfuncDon?–  Shenowspends50%ofthedayresDng–  Shehasbeenoffworkforthepastfewmonths–  Shehasstoppedexercising–sheusedtogotothegymorgoforahikeafewDmesaweekwhichsheenjoyed

•  Currentdiet,nutriDon,substanceuse?–  Sheeatsafairlybalanceddiet– Alcohol–2glassesofwine3-4x/week– Nosmokingordruguse– Doesnottakeanyvitaminsorsupplements

Physical Exam: •  Shedoeshave14tenderpointsonherexam–bilateralcervical,anteriorcricothyroid,supraclavicular,bilateralgluteal,greatertrochanters,lateralepicondyles,andmedialknees

•  Nojointswellingorwarmth•  Musclestrengthandtonearenormal•  Norashesorskinlesions•  Neurologicexamisnormal

What would you include in your differential diagnosis?

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Differential Diagnosis

•  Fibromyalgia•  VitaminDdeficiency(?)•  PolymyalgiarheumaDca•  StaDninducedmyalgias•  Sleepapnea•  Depression•  Hypothyroid

What labs or studies might you order?

Work up

•  TSH•  ESR•  CPK•  VitaminD•  Sleepstudy•  PHQ-9•  DoyouorderRF,ANA?

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Patient Self Report Survey:

Self report survey:

•  WidespreadPainIndex(WPI)score:14/19

•  SymptomSeverityscore:7– FaDgue:severe:3(severe)– Troublethinkingorremembering:2(moderate)– Unrefreshingsleep:2(moderate)

•  Co-occuringcondiDons:Headaches:1

•  Depression:1TotalScore:23

Patient Self-report Survey for the Assessment of Fibromyalgia Based on

Criteria in the 2011 Modification of the ACR Preliminary Diagnostic Criteria for

Fibromyalgia. The possible score ranges from 0 to 31

points; a score ≥13 points is consistent with a diagnosis of fibromyalgia.

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All of the studies come back normal. You conclude that she has

fibromyalgia

What might be a reasonable initial treatment plan?

Fibromyalgia Initial Treatment Plan

•  EducaDon!CounselpaDentindetailregardingnaturalcourseoffibromyalgia

•  CounselpaDentaboutacDvitypacing•  Exerciseplan•  StressreducDon,mindbodypracDces–yoga,taichi,MBSR•  ConsiderstaDnholiday•  ProvidelistofpotenDallybeneficialvitaminsandsupplements

2-month Follow up

•  SheisnowparDcipaDnginaquatherapy3x/week•  ShehasbeentakingVitaminBcomplex,VitaminD1,000IU/day,magnesiumglycinate200mgbid

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She is feeling better overall, but still feels she needs more help with pain relief. Her fatigue is also better, but problematic. She is still hoping to

return to work in the next few months.

What treatments would you consider at this time?

Starting a Medication

•  ConsiderSNRIifpaDenthasasignificantconcurrentmooddisorder:– DuloxeDne60-120mgdaily

– Milnacipran50mgbid

•  Ifnomooddisorderbutpoorsleep,consideragabapenDnoid:– Pregabalin150mgbid– GabapenDn300-400mgDd

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Reasonable prn Medications

•  Analgesic:tramadol•  Musclerelaxant:cyclobenzaprine•  Sleepagent:trazodone,melatonin

•  Avoid:opiates,benzodiazepines,carisoprodol(Soma)

For Fatigue, Consider

•  AddingamindbodypracDce:TaiChi,yoga,MBSR•  TrialofaddiDonalsupplement:CarniDne2,000mg/day,D-ribose5gmsbid,CoQ10100-300mg/day,orSAMEe800mg/day

She comes back for follow-up after 2 months on pregabalin 150 mg bid, as well as recommended supplements

•  Painisbe,er

•  FaDgueisali,lebe,erwithsupplements,andregularpracDceofTaiChi

•  Feelstoogroggyonthepregabalin•  Wantstotrysomethingelse

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What might you try next?

Alternate Medications to Consider

•  DuloxeDne•  Milnacipran•  TCA–amitriptylineornortriptyline•  Lowdosenaltrexone

Patient now remembers she took duloxetine 3 years ago and had

intolerable nausea, so she does not want to try it again. She also does not want to try milnacipran for the same

reason.

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Her recent ECG revealed a prolonged QTc so you don’t want to use a TCA

You decide to do a trial of low dose

naltrexone, 4.5 mg qhs

Next 2-month follow up, her fibromyalgia treatment plan now

consists of:

•  3x/weekaquatherapy•  1x/weekTaiChiclass•  AcDvitypacing–adherestoaconsistentmoderateschedule•  VitaminBcomplex,VitaminD•  Magnesiumglycinate,CoQ10supplement•  Lowdosenaltrexone4.5mgqhs

Patient still has pain and fatigue, but manageable.

She has started looking for

part time employment

SUCCESS! (because everybody likes ahappy

ending)

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