Disclosure
This program was developed from
an educational grant from Pfizer
to the University of Calgary
and Université de Sherbrooke.
Faculty disclosure
Core Development Committee
Dr. Christian Cloutier, Neurosurgeon, Quebec
Dr. Mary-Ann Fitzcharles,
Rheumatologist, Quebec
Dr. Algis Jovaisas, Rheumatologist, Ontario
Ms. Christal Lacombe, Pharmacist, Alberta
Dr. Rhonda Shuckett, Rheumatologist,
British Columbia
Dr. Richard Ward, Family Physician, Alberta
National Committee
Dr. Brian Craig, Family Physician, New Brunswick
Dr. Alan Kaplan, Family Physician, Ontario
Dr. Bernard Martineau, Family Physician, Quebec
Dr. Kenneth Stakiw,
Family Physician, Saskatchewan
Mr. Robert Thiffault, Pharmacist, Quebec
Overall Learning Objectives
Following this program, participants will
Describe the diagnosis and core symptoms
of fibromyalgia (FM)
Have an approach to explaining the diagnosis
of FM to patients
Prescribe appropriate pharmacologic
and non-pharmacologic interventions
based on predominant symptoms
Menu (all related to FM)
1
Management of Pain
Depression
4
2
Fatigue
Making the Diagnosis
5
3
Sleep Disturbance
“Selling” the Diagnosis
6
7
Non-pharmacologic
Interventions
Choice of Medical
Therapy
8
Incomplete Treatment
Response
9
Click on the name of the module
you want to access
Objectives
Following this module, participants will be able to:
Explain the basis of increased pain in patients with
fibromyalgia (FM)
Discuss the relationship between pain, fatigue and sleep
disturbance in FM
Suggest non-pharmacologic therapies for pain
Prescribe medications that improve pain in FM
Recognize the role of an interdisciplinary team
in FM management
Core Clinical Features of FM
Neurocognitive Impairment
(“Fibro Fog”)
Widespread Pain
• Chronic, widespread pain
is the defining feature
of FM
fibromyalgia
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Characterized by confusion, slowed
processing of information and reaction time,
difficulty in word retrieval or speaking,
concentration, attention, short-term memory
consolidation, disorientation
Sleep Disturbance
• Characterized by non-restorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
• Presence of tender points
Fatigue
• Patients describe it as physically or
emotionally draining
Stiffness
• Stiffness in the morning is a common
characteristic of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci.
1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum.
2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Case Study
Patty is a 32-year-old patient in your
practice who was diagnosed with FM
that appeared to start after she slipped on
some ice.
Patty was advised to attend a local yoga
studio, which has a special FM class.
She was given a morning medication
that targeted mood.
As well, she was referred to a local FM
support group.
Video 1
Questions
1. Why do patients with FM have pain?
2. What non-medication approach
would you take with Patty?
3. What medical FM therapies improve pain?
4. How could an interdisciplinary team (your own
team or resources in your community) assist in
the management of patients with FM?
Take the time to answer each of the questions
Symptoms of FM
Pain, fatigue and sleep disturbance
are present in at least 86% of patients*
100%
100
96%
86%
72%
80
60%
60
56%
52%
46%
42%
41%
32%
40
20%
20
0
Muscular
pain
Fatigue
Insomnia
Joint
pains
Headaches
Restless Numbness Impaired
legs
and tingling memory
Leg
cramps
Impaired
Concentration
Nervousness
*United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web Site http://www.nfra.net/Diagnost.htm.
Major
depression
Pathophysiological Observations in FM
Despite extensive research, the exact cause of pain
in FM is not clearly understood
Peripheral
Peripheral sensitization
Temporal summation (windup) (short-term)
Spine and brain
Central sensitization (long-term)
Change in grey matter volume
Descending inhibition
Other factors
Hypothalamic-pituitary-adrenal axis dysregulation
Sleep disturbance
Cognitive effects
Staud et al. Nat Clin Pract Rheumatol. 2006;2:90-98; Henriksson. J Rehabil Med. 2003;41(suppl 41):89-94;
Crofford et al. Arthritis Rheum. 2002;46:1136-1138; Vaerøy et al. Pain. 1988;32:21-26; Staud. Arthritis Res.Ther. 2006;8:208.
Key Messages for Pain Principles
in FM
There is no “cure” for the pain
Active patient involvement:
activity and non-medication approaches
Important to manage patient’s expectations
Normalize sleep
Normalize mood
Start with medical interventions for pain
that have evidence for efficacy in FM
Start low, go slow!
Target pain control that allows functionality
Non-pharmacologic Treatments
Patient education
Conflicting evidence but some studies have shown
improvements in pain, sleep, fatigue and quality of life
Cognitive-behavioural therapy
Positive effects on coping with and control over pain
• Not proven to improve pain
Proven to improve physical function
Should be done by a trained professional
Aerobic and strengthening exercises
Reduce pain, increase self-efficacy, improve quality of life
and reduce depression
Aerobic exercise should be of low to moderate intensity,
2–5 times/week
Goldenberg et al. JAMA. 2004;292:2388-2395.
Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:873-886.
Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:857-871.
Modulating Factors of FM
Syndrome Pain
Factors
Exacerbating Factors
Weather (cold/humid)
Poor sleep
Anxiety/stress
Physical inactivity
Noise
Relieving Factors
Local heat
Rest
Moderate activities
Massage
Stretching exercises
Wallace et al. Fibromyalgia and Other Central Pain Syndromes. Lippincott Williams & Wilkins; 2005:126.
Mean %
65
70
61
49
22
58
54
46
40
43
Interrelationship Among Pain, Sleep
Disturbance and Psychological Symptoms
Sleep interference
can directly result
from and/or
contribute to FM
Functional
Impairment
and Fatigue
Pain
Related
Paradigm of pain
Adapted from Argoff. Clin J Pain. 2007;23:15-22.
Psychological
symptoms are
strongly associated
with FM
Sleep Deprivation and Pain
Chronic pain
Lack of sleep
Activates, maintains
central nervous system
(CNS) areas responsible
for awake state
May impair healing,
leading directly to pain
Dampens areas
responsible for initiation
and maintenance
of sleep
Affects CNS areas
responsible for coping
mechanisms useful
for dampening pain
experience
Sleep disturbances may lead directly to more pain,
and indirectly to a heightening of the pain experience
through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133.
(alphabetical order)
Medication
Mechanism of
Action
Amitriptyline
(desipramine,
doxepin,
nortriptyline)
TCA
(NE > 5HT)
Cyclobenzaprine
Muscle
relaxant (NE)
Duloxetine
SNRI
Gabapentin
Effect
on Pain
Effect on
Other
Symptoms
Off/on Label
Indication
Comments
Starting Dose and
Titration
Usual
Maintenance
Dose
+
Sleep,
anxiety
Off
Poor long term, doxepin
seldom recommended,
desipramine may cause
insomnia (administer in
morning), not well
tolerated in this
population
10-25 mg/day Increase
weekly by 10 mg/day
50-150 mg/day
+
Sleep
Off
Poor long term
10 mg 3 times/day
10 mg 3 times/day
(range of 20-40
mg/day in divided
doses, max 60
mg/day)
+++
Depression,
anxiety
On
60 mg/day
(can start at 30 mg for
tolerability reasons with
target of 60 mg/day in 1-2
weeks)
60-120 mg/day
2 binding:
↓neuronal
excitation
++
Sleep,
anxiety
Off
300 mg 3 times/day;
increase with 300- or 400mg capsules, or 600- or
800-mg tablets 3 times/daily
3 times/day up to
1800 mg/day
Pramipexole
Dopamine
agonist
+
Fatigue
Off
Start 0.375 mg/day in 3
divided doses; increase
gradually no more
frequently than every 5-7
days
1.5 to 4.5 mg/day in
equally divided doses
3 times/day
Pregabalin
2 binding:
↓neuronal
excitation
+++
Sleep,
anxiety
On
150 mg/day in 2 divided
doses; increase by 150
mg/day after 1 week
300-450 mg in 2
divided doses
Tramadol
Opioid agonist
SNRI
++
Off
25 mg/day; increase by 25
mg/day every 3 days to 50
mg 4 times/day
50-100 mg 4
times/day
Best Evidence: FM Pain Medication
Limited population
studied
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant
No/Poor Evidence: FM Pain Medication
(alphabetical order)
Medication
Mechanism of
Action
Rationale for Use
Concern for Use
Benzodiazepines
GABA increase
Anxiety
Addiction
Side effects
Cannabinoids
CB 1 receptor
agonist
Improves sleep
Lack of
effectiveness in
FM pain
Side effects
NSAIDs
Prostaglandin
inhibition
Analgesia
NSAID-related
side effects
Opioids
Opioid receptor
agonists
Analgesia
Addiction
Side effects
See new national
guidelines
NSAID, non-steroidal anti-inflammatory drug
Video 2
Video de-brief
Summary
Pain is the most common symptom of FM
Set realistic treatment goals
Use non-pharmacologic treatments first
Use medical therapies that target pain and
have evidence for efficacy in FM as
first-line pharmacotherapy
Balance medication side effects and risk
with optimizing function
Menu
Objectives
Following this module, participants will be able to:
Provide a differential diagnosis of fatigue
in patients with fibromyalgia (FM)
Prescribe therapies that will improve fatigue in FM
Assist patients in establishing reasonable treatment goals
Recognize the role of an interdisciplinary team
in FM management
Core Clinical Features of FM
Neurocognitive Impairment
(“Fibro Fog”)
Widespread Pain
• Chronic, widespread pain
is the defining feature
of FM
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Characterized by confusion, slowed
processing of information and reaction time,
difficulty in word retrieval or speaking,
concentration, attention, short-term memory
consolidation, disorientation
Sleep Disturbance
• Characterized by non-restorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
• Presence of tender points
Fatigue
• Patients describe it as physically or
emotionally draining
Stiffness
• Stiffness in the morning is a common
characteristic of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci.
1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum.
2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
Patty signed up at a local gym to take aerobic
exercise classes at your suggestion.
She was given a bedtime medication to
improve her sleep and referred to a website
that provides information for patients
with FM.
Video 1
Questions
1. In patients with an established diagnosis of FM,
what factors should be considered when
evaluating fatigue?
2. What non-medication approach would you take
with Patty?
3. What FM medications target fatigue?
4. How could an interdisciplinary team
(your own team or resources in your community)
assist in the management of patients with FM?
What other healthcare professional could help?
Take the time to answer each of the questions
Symptoms of FM
Pain, fatigue and sleep disturbance
are present in at least 86% of patients*
100%
100
96%
86%
72%
80
60%
60
56%
52%
46%
42%
41%
32%
40
20%
20
0
Muscular
pain
Fatigue
Insomnia
Joint
pains
Headaches
Restless Numbness Impaired
legs
and tingling memory
Leg
cramps
Impaired
Concentration
Nervousness
*United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Major
depression
Things to Consider when FM Patients
Complain of Fatigue
1.
2.
3.
4.
5.
6.
Sleep disturbance
Uncontrolled pain
Depression
Unrealistic expectations
“Stress” caused by illness
Medication side effects
(especially polypharmacy)
7. Deconditioning
8. Unrecognized new illness*
* Avoid the trap of re-investigating the patient with firmly diagnosed FM,
but remember: eventually all FM patients will get another disease!
Fatigue in Primary Care –
One-Year Follow-Up
46.9% of those with the initial
presentation of fatigue and with
no diagnosis made at the time of
presentation had, at the end of
one year, one or more of these
diagnoses that could possibly be
the cause of their fatigue.
Note that of musculoskeletal
complaints, most were deemed
non-specific.
Documentation at initiation of
study indicated that 24.1% of
patients had depressive
symptoms. Diagnosis of
depression was made in 4.9%
of subjects at one year.
Nijrolder et al. CMAJ. 2009;181:683-687.
1. Musculoskeletal (19.4%)
2. Psychosocial (16.5%)
3. Gastrointestinal (8.1%)
4. Neurological (6.7%)
5. General (4.9%)
6. Respiratory (4.9%)
7. Endocrine (2.8%)
8. Cardiovascular (1.9%)
9. Menopause (1.1%)
10. Malignancy (.7%)
Interrelationship Among Pain, Sleep
Disturbance and Psychological Symptoms
Sleep interference
can directly result
from and/or
contribute to FM
Functional
Impairment
and Fatigue
Pain
Related
Paradigm of pain
Adapted from Argoff. Clin J Pain. 2007;23:15-22
Psychological
symptoms are
strongly associated
with FM
Sleep Deprivation and Pain
Chronic pain
Lack of sleep
Activates, maintains
central nervous system
(CNS) areas responsible
for awake state
May impair healing,
leading directly to pain
Dampens areas
responsible for initiation
and maintenance
of sleep
Affects CNS areas
responsible for coping
mechanisms useful
for dampening pain
experience
Sleep disturbances may lead directly to more pain,
and indirectly to a heightening of the pain experience
through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133
Utility of FM Medications
Targeting Fatigue
There are no generally accepted,
on-label medications that improve
the fatigue associated with FM
Physical activity is the only
non-pharmacologic strategy proven
to reduce fatigue
What is helpful for complaints of fatigue?
Improvement of sleep hygiene
Moderate physical activity
Pacing
Realistic goal setting
Healthy eating
Cognitive behavioral therapy (CBT)
Lera et al. J Psychosom Res. 2009;67:433-441.
Rossy et al. Ann Behav Med. 1999;21:180-191.
Williams. Best Pract Res Clin Rheumatol. 2003;17:649-665.
Medications with Anti-fatigue Properties
(alphabetical order)
Medication
Mechanism
of Action
Bupropion
NE
Dopamine
Duloxetine
Effect on
Fatigue
Effect on
Other
Symptoms
Comments
-
Depression
More “energizing”
antidepressant
SNRI
+
Pain,
depression,
anxiety
Improvement in fatigue
as secondary endpoint
Modafinil
Dopamine
NE
+
Pramipexole
Dopamine
agonist
+
Stimulants
(methylphenidate,
dextroamphetamine)
NE
Dopamine
-
Open label small study
Pain
Off label - limited
population studied
No evidence
Addiction properties so
caution
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor
Video 2
Video de-brief
Summary
When fatigue is the primary complaint,
evaluate sleep and pain control, and rule
out depression
Use of medications may improve fatigue
Help patients set realistic goals for
improvement of fatigue
Important role of non-pharmacologic
interventions, especially physical activities
Menu
Objectives
Following this module, participants will be able to:
Recognize the relationship between sleep restoration and
symptom improvement in patients with fibromyalgia (FM)
Provide non-pharmacologic therapies to improve
sleep disturbance
Prescribe medications that target sleep and other
FM symptoms
Recognize the role of the interdisciplinary team
in FM management
Core Clinical Features of FM
Neurocognitive Impairment
(“Fibro Fog”)
Widespread Pain
• Chronic, widespread pain
is the defining feature
of FM
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Characterized by confusion, slowed
processing of information and reaction time,
difficulty in word retrieval or speaking,
concentration, attention, short-term memory
consolidation, disorientation
Sleep Disturbance
• Characterized by non-restorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
• Presence of tender points
Fatigue
• Patients describe it as physically or
emotionally draining
Stiffness
• Stiffness in the morning is a common
characteristic of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci.
1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum.
2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
Patty was advised to attend a local yoga
studio, which has a special FM class.
She was given a morning medication
that targeted mood and pain.
She was encouraged to review a website that
provides information for patients with FM.
Video 1
Questions
1. What elements should you consider when
evaluating Patty’s sleep problems?
2. What non-medication approach would you take
with Patty?
3. What FM medications improve sleep problems?
4. How could an interdisciplinary team (your own
team or resources in your community) assist
in the management of patients with FM?
Take the time to answer each of the questions
Symptoms of FM
Pain, fatigue and sleep disturbance are
present in at least 86% of patients*
100%
100
96%
86%
72%
80
60%
60
56%
52%
46%
42%
41%
32%
40
20%
20
0
Muscular
pain
Fatigue
Insomnia
Joint
pains
Headaches
Restless Numbness Impaired
legs
and tingling memory
Leg
cramps
Impaired
Concentration
Nervousness
* United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Major
depression
Differential Diagnoses to Consider
with Sleep Disorders
Pain
Poor sleep hygiene
Medication side effects (including caffeine)
Anxiety/depression/bipolar disorder
Other sleep disorders (restless leg
syndrome, obstructive sleep apnea, etc.)
Interrelationship Among Pain, Sleep
Disturbance and Psychological Symptoms
Sleep interference
can directly result
from and/or
contribute to FM
Functional
Impairment
and Fatigue
Pain
Related
Paradigm of pain
Adapted from Argoff. Clin J Pain. 2007;23:15-22.
Psychological
symptoms are
strongly associated
with FM
Sleep Deprivation and Pain
Chronic pain
Lack of sleep
Activates, maintains
central nervous system
(CNS) areas responsible
for awake state
May impair healing,
leading directly to pain
Dampens areas
responsible for initiation
and maintenance
of sleep
Affects CNS areas
responsible for coping
mechanisms useful
for dampening pain
experience
Sleep disturbances may lead directly to more pain,
and indirectly to a heightening of the pain experience
through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs 2003;4:124-133.
Pain Leads to Sleep Disruption
Result of noxious pain stimuli = arousal
Decrease in delta waves
Increase in alpha waves
In FM: the structure of the sleep is modified and
there is fragmentation of sleep
Drewes et al. Sleep. 1997;20:632-640.
Non-pharmacologic Interventions
to Improve Sleep
1. Avoid stimulants
2. Regular time to go to bed and to rise
3. Avoid napping through day
4. Regular AM exercise
5. Bed is for sleep and sex
6. Relaxation before bed
7. Sleep handout for patients
www.tufts.edu/med/phfm/pdf/fm-handouts/SleepHygiene.pdf
Medications and Effects on Sleep
(alphabetical order)
Medication
Effect on Sleep
Effect on Pain
Amitriptyline (desipramine,
doxepin, nortriptyline)
+++
+ (poor long-term)
Atypical antipsychotics
+++
±
Benzodiazepines
+++
-
Cannabinoids
+++
+
Cyclobenzaprine
+++
+ (poor long-term)
Duloxetine
+
+++
Gabapentin
++
++
Pregabalin
+++
+++
Zopiclone
+++
-
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
Evidence for effect on sleep is mostly within non-pain patients and has been collected by polysomnography. The only evidence from patients
with pain is with pregabalin through patient diaries and Medical Outcomes Study Sleep scores
Video 2
Video de-brief
Summary
Rule out secondary causes
of sleep disorders
Consider lifestyle modification as a first
step to manage sleep problems
Consider pain/sleep/fatigue cycle
when considering therapies
Use medical therapies that target sleep
when it is prevalent disabling symptom
Menu
Objectives
Following this module, participants will be able to:
Differentiate fibromyalgia (FM) from depression
Prescribe therapies that will improve both FM
and depression
Have an approach to explaining depression and FM
to patients
Use an interdisciplinary team to manage patients with FM
Core Clinical Features of FM
Neurocognitive Impairment
(“Fibro Fog”)
Widespread Pain
• Chronic, widespread pain
is the defining feature
of FM
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Characterized by confusion, slowed
processing of information and reaction time,
difficulty in word retrieval or speaking,
concentration, attention, short-term memory
consolidation, disorientation
Sleep Disturbance
• Characterized by non-restorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
• Presence of tender points
Fatigue
• Patients describe it as physically or
emotionally draining
Stiffness
• Stiffness in the morning is a common
characteristic of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci.
1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum.
2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
Patty was referred to a “Living with FM”
lifestyle program run by a local
physiotherapist. She was advised to work on
lifestyle and sleep hygiene, and to use a
simple over-the-counter analgesic for
pain control.
She presents for follow-up complaining
that the interventions are “not effective.”
Video 1
Questions
1. Is FM just depression with pain?
2. What treatment modalities may be indicated in
this patient?
3. How would you convince Patty that an
antidepressant medication would be
a good choice?
4. How could an interdisciplinary team
(your own team or resources in your community)
assist in the management of patients with FM?
Take the time to answer each of the questions
Symptoms in FM Syndrome
SYMPTOMS
MEAN
(%)
Musculoskeletal
SYMPTOMS
MEAN
(%)
Non-musculoskeletal
Pain at multiple sites
100
Anxiety
60
Stiffness
76
Mental stress
61
“Hurt all over”
62
Depression
37
Swollen feeling in tissues
52
Cognitive dysfunction
61
Non-musculoskeletal
Selected Associated Syndromes
General fatigue
87
Headaches
54
Morning fatigue
75
Dysmenorrhea
43
Sleep difficulties
72
Irritable bowel syndrome
38
Paresthesia
54
Restless legs syndrome
31
Dizziness/vertigo
59
15
Tinnitus
17
Female urethral
syndrome
Sicca symptoms
15
Raynaud phenomenon
14
Wallace et al. Fibromyalgia and Other Central Pain Syndromes. Lippincott Williams & Wilkins; 2005:126.
How Patients with Psychiatric
Disorders Initially Present to
Primary Care Physicians1
Strong Correlation Between
Number of Physical Symptoms and
Prevalence of Psychiatric Disorders2
Anxiety disorder
Mood disorder
83%
100
80
60
40
17%
20
0
Somatic
Patients with psychiatric
disorders (%)
Any psychiatric disorder
100
Psychological
Most people with psychological problems
go to their family doctor with a physical
complaint rather than recognizing that
they have a form of mental distress.
80
60
40
20
0
0-1
2-3
4-5
6-8
≥9
Number of physical complaints
The more physical complaints
there are, the more likely there is a
psychiatric problem.
1. Kirmayer et al. Am J Psychiatry. 1993;150:734-741. 2. Kroenke et al. Arch Fam Med. 1994; 3:774-779.
Somatic Symptoms
Common in Psychiatric Patients
Symptom
Psychiatric
Healthy
Tired, lack of energy
85%
40%
Headache, head pains
64%
48%
Dizzy or faint
60%
14%
Parts of body felt weak
57%
23%
Muscle pains, aches, rheumatism
53%
27%
Stomach pains
51%
20%
Chest pains
46%
14%
Adapted from Kellner R and Sheffield BF. Am J Psychiatry. 1973;130:102-105.
Maintain a High Index of Suspicion
for the Diagnosis of Major Depressive Disorder
In patients with:
Multiple physical symptoms
Frequent visits and thick charts
Poor sleep, fatigue
Chronic pain (including FM, migraines,
irritable bowel syndrome)
Anxiety disorders
Substance-use disorders
Attention-deficit/hyperactivity disorder
Type II diabetes, ischemic heart disease,
cerebrovascular accidents, cancer, osteoporosis
Mood Disorders in FM
At time of diagnosis, approximately
20%–40% of individuals with FM have an
identifiable current mood disorder
(e.g., depression or anxiety)
Lifetime prevalence of depression: 74%
Lifetime prevalence of anxiety disorder: 60%
In many cases, depression or anxiety may be
the result of chronic pain
Katon et al. Ann Intern Med. 2001;134:917-925.
Boissevain et al. Pain. 1991;45:227-238.
Boissevain et al. Pain. 1991;45:239-248.
Giesecke et al. Arthritis Rheum. 2003;48:2916–2922.
Arnold et al. Arthritis Rheum. 2004;50:944–952.
Fishbain et al. Clin J Pain. 1997;13:116–137.
Strategy for Explaining Depression
Reinforce neurobiological basis of depression
Acknowledge that chronic pain and depression
frequently co-exist
Use the symptom complex for depression –
SIGECAPS – to help patients understand
symptom grouping
Encourage bibliotherapy to reinforce concepts
Use other members of healthcare team to assist
in psychoeducation
SIGECAPS, mnemonic mnemonic for symptoms of major depression and dysthymia (sleep disorder, interest deficit, guilt, energy deficit,
concentration deficit, appetite disorder, psychomotor retardation or agitation, suicidality)
Non-pharmacologic Treatment
Evidence for effectiveness of cognitive
behavioral therapy (CBT) for both
depression and FM
Bennett et al. Nat Clin Pract Rheumatol. 2006;2:416-424.
Whitfield et al. Advances Psychiat Treat. 2003;9:21-30.
Medications for FM that Have Mood
Regulation and Anxiolytic Properties
(alphabetical order)
Medication
Mechanism of
Action
Amitriptyline
(desipramine,
doxepin,
nortriptyline)
TCA
(NE > 5HT)
Bupropion
Effect on
Mood/Anxiety
Effect on Other
Symptoms
Off/on- Label
Indication For FM
Comments
+
Pain, sleep
Off
FM doses < usual
antidepressant dose
Atypical antidepressant
++
Fatigue
Off
More “energizing”
antidepressant
Duloxetine
SNRI
+++
Pain
On
Gabapentin
2 binding:
↓neuronal
excitation
++
Pain, sleep
Off
Address anxiety
reduction properties
Pregabalin
2 binding:
↓neuronal
excitation
+++
Pain, sleep
On
Address anxiety
reduction properties
Sertraline
SSRI
++
Pain
Off
Compared versus physical
therapy
Venlafaxine
SNRI > SSRI
++
Pain
Off
Open-label small studies,
limited effect on FM pain
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor;
SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant
Video 2
Video de-brief
Summary
FM is common, depression is common. They
frequently occur together but are separate disorders
Patient education is key
Use an interdisciplinary team and multimodal
therapies to help treat FM and comorbid depression
Use pharmacologic and non-pharmacologic
(especially CBT) strategies
Therapies that may treat both include CBT and
antidepressants with analgesic properties
Menu
Following this module, participants
will be able to:
Give the prevalence demographics
of fibromyalgia (FM)
Make a diagnosis of FM
Order appropriate investigations
for patients with suspected FM
Provide a differential diagnosis
for patients presenting with widespread
pain, fatigue and sleep problems
Objectives
Case Study
Patty is a 32-year-old woman
in your practice
History:
Under your care for 10 years
Unremarkable past history
Slipped on ice 4 months ago and has had
progressive generalized pain and fatigue
Saw a locum 2 weeks ago who ran a battery
of tests for multiple symptoms of generalized
pain, fatigue and sleep problems
Video 1
Questions
1. What is the incidence and gender
distribution of FM?
2. How do you make the diagnosis
of FM?
3. What are the differential diagnoses
in this patient?
4. What investigations would you have
ordered 2 weeks ago?
Take the time to answer each of the questions
Prevalence of FM
FM occurs in all ages, both sexes and all
cultures, but occurs more frequently in:
Women
Patients between the ages of 35–60 years
In Canada:
FM affects an estimated 4.9% of adult women
and 1.6% of adult men
Female-to-male ratio of approximately 3:1
Cardiel et al. Clin Exp Rheumatol. 2002;20:617-624; Carmona et al. Ann Rheum Dis. 2001;60:1040-1045; Lawrence et al. Arthritis Rheum. 1998;41:778799; Lindell et al. Scand J Prim Health Care. 2000;18:149-153; Neumann et al. Curr Pain Headache Rep. 2003;7:362-368; Prescott et al. Scand J
Rheumatol. 1993;22:233-237; White et al. J Rheumatol. 1999; 26:1570-1576; Wolfe F. J Musculoskeletal Pain. 1993;3:137-148; Wolfe et al. Arthritis
Rheum. 1995;38:19-28;.
Core Clinical Features of FM
Neurocognitive Impairment
(“Fibro Fog”)
Widespread Pain
• Chronic, widespread pain
is the defining feature
of FM
• Patient descriptors of pain
include: aching, exhausting,
nagging, and hurting
• Characterized by confusion, slowed
processing of information and reaction time,
difficulty in word retrieval or speaking,
concentration, attention, short-term memory
consolidation, disorientation
Sleep Disturbance
• Characterized by non-restorative sleep
and increased awakenings
• Abnormalities in the continuity of sleep
and sleep architecture
• Presence of tender points
Fatigue
• Patients describe it as physically or
emotionally draining
Stiffness
• Stiffness in the morning is a common
characteristic of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci.
1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum.
2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
Symptoms of FM
Pain, fatigue and sleep disturbance
are present in at least 86% of patients*
100%
100
96%
86%
72%
80
60%
60
56%
52%
46%
42%
41%
32%
40
20%
20
0
Muscular
pain
Fatigue
Insomnia
Joint
pains
Headaches
Restless Numbness Impaired
legs
and tingling memory
Leg
cramps
Impaired
Concentration
Nervousness
*United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Major
depression
Mood Disorders in FM
At time of diagnosis, approximately
20%-40% of individuals with FM have an
identifiable current mood disorder
(e.g., depression or anxiety)
Lifetime prevalence of depression: 74%
Lifetime prevalence of anxiety disorder: 60%
In many cases, depression or anxiety
may be the result of chronic pain
Arnold et al. Arthritis Rheum. 2004;50:944–952; Boissevain et al. Pain. 1991;45:227-238; Boissevain et al. Pain. 1991;45:239-248; Fishbain et al. Clin J Pain.
1997;13:116–137; Giesecke et al. Arthritis Rheum. 2003;48:2916–2922; Katon et al. Ann Intern Med. 2001;134:917-925.
Stressors
Some triggering event may trigger FM but is not
a prerequisite
In many cases, onset of FM is gradual, with no
identifiable trigger
Stressors that may trigger FM
Peripheral pain syndromes, physical trauma, infections
(e.g., parvovirus, Epstein-Barr virus, Lyme disease, Q fever),
psychological stress/distress, including sleep disturbances
The development of FM after a precipitating event
may represent the onset of a prolonged and disabling
pain syndrome with considerable social and
economic implications
Greenfield et al. Arthritis Rheum. 1992;35:678-681.
McLean et al. Med Hypotheses. 2004;63:653-658.
FM as a Consequence
of Trauma
Factors Triggering FM or Associated with its Onset (n=136)
Trigger Factors
Cold
Stress
Emotions
Overwork
Trauma
Surgery
Death in the family
Family problems
Fatigue
No cause/association
Associated Factors*
0
9
5
0
24
4
0
2
0
55
*More than one factor possible for the same patient
In most cases of FM, there is no predisposing trigger.
Adapted from Wolfe F. Am J Med. 1986;81:7-14.
15
35
35
22
24
13
13
25
23
5
Diagnosing FM:
Overview
Patient history of FM or related conditions
Personal history
Family history
Physical examination
Most important to rule out other conditions
Differential diagnosis
Clinical/laboratory evaluation to exclude other conditions
such as:
• Osteoarthritis, rheumatoid arthritis, polymyalgia rheumatica
(PMR), hypothyroidism, lupus and Sjögren’s syndrome
Note: Extensive lab evaluation is usually not necessary to rule out FM, In some cases,
a thyroid-stimulating hormone test may be called for. PMR is usually not a problem as it seldom
occurs under the age of 60, whereas the onset of FM after 65 is rare.
Mease. J Rheumatol. 2005;32(suppl 75):6-21; Wolfe et al. Arthritis Rheum. 1990;33:160-172.
Evolution of FM Diagnosis
Evaluation of tender points
Identification of symptoms complex
New Canadian guidelines being developed
Assessment of FM:
American College of Rheumatology (ACR)
Classification Criteria (1990)
History of widespread pain that
has been present for at least
3 months
(ALL of the following should be
present):
Pain on both sides of the body
Pain above and below
the waist
Axial skeletal pain
Pain in at least 11 of 18 tender
point sites on digital palpation
Wolf et al. Arthritis Rheum. 1990;33:160-172.
ACR criteria are both
sensitive (88.4%) and specific (81.1%)
ACR New Proposed Diagnostic Criteria for FM –
2010 (1)
FM can be diagnosed if:
Symptoms for at least 3 months
No other condition to explain pain
Pain + associated symptoms
Wolfe et al. Arthritis Care Res (Hoboken). 2010;62:600-610.
ACR New Proposed Diagnostic Criteria for FM –
2010 (2)
Associated symptoms include:
Unrefreshed sleep
Cognitive symptoms
Fatigue
Other somatic symptoms
Wolfe et al. Arthritis Care Res (Hoboken). 2010;62:600-610.
Summary
FM is a common disease of middle age
with a female-to-male ratio of 3:1
Simple investigations and history will exclude
other rheumatologic or psychiatric conditions
The 4 cardinal symptoms of FM include
widespread pain, fatigue, sleep disturbance
and cognitive slowing
The current diagnosis of FM is based on
widespread pain plus associated symptom cluster
with a physical exam to exclude other conditions
Menu
Following this module, participants will be able to :
Explain the known pathophysiology of fibromyalgia (FM)
Provide the natural history of FM
Negotiate and explain the diagnosis of FM
Use multidisciplinary and other resources to help educate
patients around the diagnosis of FM
Objectives
Case Study
Patty is a 32-year-old woman
in your practice
History:
Under your care for 10 years
Unremarkable past history
Slipped on ice 4 months ago and has had
progressive generalized pain and fatigue
Saw a locum 2 weeks ago who ran a battery of
tests for multiple symptoms of generalized
pain, fatigue and sleep problems
Clinical exam confirms diagnosis of FM
Video 1
Questions
1. What is FM? How would you explain it
to Patty?
2. What is the natural history of FM?
3. Is it better to “label” Patty with the
diagnosis of FM?
4. What other strategies could you use
to educate Patty about the disease?
Take the time to answer each of the questions
Pathogenesis of FM:
Overview
FM is a condition of global dysregulation
of pain processing
Central sensitization is one component
Mechanisms of central sensitization
Excitatory mechanisms
Inhibitory mechanisms
Price DD, Staud R. J Rheumatol. 2005;32 (Suppl 75):22-28.
Pathophysiological Changes
in FM
Increased levels of substance P (>3x)
in patients with FM
Functional magnetic resonance imaging
(fMRI) studies show a marked regional
increase in cerebral blood flow following
a painful stimulus in patients with FM
compared to controls not suffering FM
Deficit in the endogenous pain inhibitory
systems noted in FM patients
Vaerøy et al. Pain. 1988;32:21-26.; Russell et al. Arthritis Rheum. 1994;37:1593-1601. ; Russell et al. In: Russell, ed. Myopain ’95: Abstracts from the 3rd
World Congress on Myofascial Pain and Fibromyalgia. San Antonio, Tex; July 30-August 3, 1995.Gracely et al. Arthritis Rheum. 2002;46:1333-1343.; Julien
et al. Pain. 2005;114:295-302.
Diagnosis Can Improve
Patient Satisfaction
Diagnosis of FM improves
health satisfaction
Patient health satisfaction
5
Improvement
White et al conducted a
prospective, community
comparison of FM patients in
Canada that revealed
significantly improved scores
36 months post-diagnosis
Patients self-reported
health satisfaction on
a 5-point Likert scale
Improvement in Patient
Health Satisfaction
4
3
3
2.2*
2
1
0
Baseline
Post-diagnosis
*Statistically significant versus baseline (confidence interval -1.2, -0.4)
Goldenberg et al. JAMA. 2004;292:2388-2395.
White et al. Arthritis Rheum. 2002;47:260-265.
Health Economic Consequences
Related to the Diagnosis of FM
Tests and Imaging
Referrals
General Practitioner Visits
Drugs
United Kingdom figures
Annemans et al. Arthritis Rheum 2008;58:895-902.
Fate of Patients with FM
Reassure patients that FM is not progressive and
that symptoms remain stable over time1
50% were moderately to greatly improved
(3 year follow-up)2
• The baseline predictors for a favorable outcome: younger age
and less sleep disturbance2
Successful management requires an upbeat,
optimistic approach and EARLY initiation of
effective, individualized therapy
Therefore, it is important to manage
patient’s expectations
1. Kennedy et al. Arthritis Rheum. 1996;39:682-685.
2. Fitzcharles et al. J Rheumatol. 2003;30:154-159.
Video 2
Video de-brief
Some Tips on Providing the Diagnosis
Be specific about the diagnosis
Be positive about the diagnosis
Promote and encourage patient self-efficacy
around the disease but . . .
Set realistic expectations
Emphasize no cure but improved control
of symptoms usually possible
Active treatments generally superior
to passive treatments
Other Useful Websites/Patient Information
National ME/FM Action Network:
http://www.mefmaction.net
Arthritis Society of Canada: www.arthritis.ca
Patient workbooks/materials
Starlanyl D, Copeland ME. Fibromyalgia & Chronic
Myofascial Pain Syndrome: A Survival Manual. 2nd ed.
Oakland, CA : New Harbinger Publications; 2001.
Fennell PA. The Chronic Illness Workbook: Strategies And
Solutions for Taking Back Your Life. 2nd ed. Latham, NY:
Albany Health Management Publishing; 2007.
Bested AC, Logan AC. Hope and Help for Chronic Fatigue
Syndrome and Fibromyalgia. 2nd ed. Nashville, TN:
Cumberland House; 2008.
Local Resources
[Facilitators to include list of local FM
resources for patients/physicians]
Summary
FM is a neurobiological dysfunction
Providing a positive diagnosis improves
health outcomes and reduces costs
The natural history of FM is variable.
Significant numbers of patients will improve
Use Internet and written resources and
other members of a multidisciplinary team
to educate patients
Menu
Following this module, participants will be able to:
Assess motivation in patients with fibromyalgia (FM)
Use simple strategies to increase patients’ readiness
to incorporate non-pharmacologic and lifestyle
Give evidence-based, non-pharmacologic interventions
as treatment for FM
Recognize the role of an interdisciplinary team
in FM management
Objectives
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
Patty was advised to attend a local “new
movement class” targeting de-conditioned
patients to increase physical activity.
She was also prescribed a medication
that would target pain – her most
disabling symptom.
Video 1
Questions
1. What non-pharmacologic interventions
have been shown to help with FM?
2. How might you help to motivate Patty?
3. How could your interdisciplinary team
(your own team or resources in your
community) assist in the management
of patients with FM?
Take the time to answer each of the questions
Management of FM:
Recommended Treatment Approach
Multidisciplinary therapy individualized to patients’
symptoms and presentation is recommended
A combination of non-pharmacologic and
pharmacologic therapies may benefit most patients
Non-pharmacologic
Aerobic exercise
Cognitive behavioral therapy (CBT)
Patient education
Strength training
Acupuncture*
Biofeedback*
Balneotherapy*
*Limited evidence for efficacy exists
Balneotherapy: treatment of disease or health conditions by bathing
Goldenberg et al. JAMA. 2004;292:2388-2395.
Non-pharmacologic Treatments with
Demonstrated Efficacy Currently in Use
CBT
Positive effects on coping with and control over pain
• Not proven to improve pain
Proven to improve physical function
Should be done by a trained professional
Aerobic and strengthening exercises
Reduce pain, increase self-efficacy, improve quality of life and
reduce depression
Aerobic exercise should be of low-to-moderate intensity,
2–5 times/week
Patient education
Conflicting evidence but some studies have shown improvements
in pain, sleep, fatigue and quality of life
Goldenberg et al. JAMA. 2004;292:2388-2395.
Brosseau L, et al. Phys Ther. 2008;88:857-71.
Brosseau L, et al. Phys Ther. 2008;88:873-86.
Alternative/Chiropractic treatments
for FM
Strong evidence supports aerobic exercise
and CBT
Moderate evidence supports massage,
muscle strength training, acupuncture
and spa therapy (balneotherapy)
Limited evidence supports spinal
manipulation, movement/body awareness,
vitamins, herbs and dietary modification
Schneider et al. J Manipulative Physiol Ther. 2009;32:25-40.
Useful Websites/Patient Information
National ME/FM Action Network:
http://www.mefmaction.net
Arthritis Society of Canada: www.arthritis.ca
Patient workbooks/materials:
Starlanyl D, Copeland ME. Fibromyalgia & Chronic Myofascial
Pain Syndrome: A Survival Manual. 2nd ed. Oakland, CA : New
Harbinger Publications; 2001.
Fennell PA. The Chronic Illness Workbook: Strategies And
Solutions for Taking Back Your Life. 2nd ed. Latham, NY: Albany
Health Management Publishing; 2007.
Bested AC, Logan AC. Hope and Help for Chronic Fatigue
Syndrome and Fibromyalgia. 2nd ed. Nashville, TN: Cumberland
House; 2008.
Local resources
Helping patients embrace lifestyle
choices — improving self-efficacy
Conviction and Confidence:
A Model for Successful Interventions
Patient conviction (i.e., sense of the patient’s
personal, emotional recognition of the benefits
of changing a behaviour)
“Is increasing your physical activity a priority for you?”
Patient confidence (i.e., sense of the patient’s
ability to modify a behaviour)
“If you did decide to become physically active,
how confident are you that you would be able
to follow though?”
Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.
Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press; 1991.
Conviction – Confidence Model
SUCCESS
CONVINCED
EMPOWERED
(Benefits)
FRUSTRATION
AMBIVALENT
CONVICTION
10
LACK OF
KNOWLEDGE
CYNICISM
SKEPTICISM
0
10
POWERLESS
(Barriers)
UNWAVERING
CONFIDENCE
Adapted from Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.; Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press;
1991.
How to Increase Conviction
Get patients to articulate
benefits of change
How to Increase Confidence
Identify barriers to change and help
patients overcome those barriers
by identifying their own solutions
A Model for
Successful Interventions
Frustration
Action
Patty
(Benefits)
Success
Empowered
Preparation
Contemplation
Lack of
knowledge
Ambivalent
Conviction
Convinced
10
Skepticism
Cynicism
Pre-contemplation
0
10
Powerless
(Barriers)
Unwavering
Confidence
Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.; Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press; 1991.
Video 2
Video de-brief
Summary
Non-pharmacologic therapies are an
important first-line treatment for patients
with FM
Compliance to lifestyle interventions can be
increased by assessing and intervening
with motivational interviewing techniques
The use of multidisciplinary resources
can improve outcomes and facilitate
time-efficient treatment
Menu
Following this module, participants will be able to:
Link the medications useful in treatment
of fibromyalgia (FM)
Match medication properties and side effects
with therapeutic targets for patients with FM
Articulate safety issues with medications commonly
used to treat FM
Objectives
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
She presented with a typical symptom complex:
generalized pain, fatigue, non-restorative
broken sleep and mental fogging.
You asked her after the first visit to review
medication options with a pharmacist who
works as part of your interdisciplinary team.
Exercise
Complete the worksheet with your partner
For each class of medication, indicate what is the effect of each symptom, using -, +, ++ or +++, and describe the most common side effects.
Class
Medications
Overall
FM
Antiepileptic
analgesics
Pregabalin*
Gabapentin
Atypical antidepressants
Bupropion
Atypical antipsychotics
Benzodiazepines
Cannabinoids
Dopamine agonist
Pramipexole
Dopamine NE
Modafinil
Muscle relaxant (NE)
Cyclobenzaprine
NSAIDs
Opioids
Opioid agonist SNRI
Tramadol
Psycho-stimulants
Dextroamphetamine,
methylphenidate
SNRI
Duloxetine*
Venlafaxine
SSRI
Sertraline
TCA
Amitriptyline
(desipramine,
doxepin,
nortriptyline)
Zopiclone
*Medication with official indication in fibromyalgia
Pain
Fatigue
Sleep
Depression/
anxiety
Most common side effects seen in patients,
based on your experience
Video 1
Video de-brief
Medical Management of FM:
Considerations
Don’t set unrealistic goals;
target functional improvement
Important to manage patient’s expectations
Keep the patient involved
in treatment decisions
Balance efficacy with side effects
Avoid rapid dose escalation:
start low, go slow!
Medical Management of FM:
Considerations (cont’d)
Use opioids with caution; keep doses low
Refer to the new Canadian practice
guideline on use of chronic opioid therapy
for non-cancer pain
Always augment with non-medical therapy
Polypharmacy may be necessary, but
keep doses low and be mindful of side
effects and function
Polypharmacy
Often necessary for symptom control
May exacerbate or cause some
of the target symptoms of FM (cognitive
impairment, sleep disturbance, fatigue)
Be aware of drug interactions
(e.g., serotonin syndrome)
Best Evidence:
Medication Options in FM
(alphabetical order)
Medication
Mechanism of
Action
Amitriptyline
(desipramine,
doxepin,
nortriptyline)
TCA
(NE > 5HT)
Duloxetine
SNRI
Gabapentin
Efficacy in
Overall FM
Management
Effect on Major
Symptoms
Off/OnLabel
Indication
Pain, sleep,
anxiety
(poor long term)
Off
+++
Pain,
depression,
anxiety
On
2 binding:
↓neuronal excitation
++
Pain, sleep,
anxiety
Off
Pregabalin
2 binding:
↓neuronal excitation
+++
Pain, sleep,
anxiety
On
Tramadol
Opioid agonist
SNRI
++
Pain
Off
+
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant
Some Evidence:
Medication Options in FM
(alphabetical order)
Effect on
Major
Symptoms
Off/onLabel
Indication
Comments
±
Sleep
Off
Open label study
CB 1 receptor
agonist
+
Sleep
Off
Lack of
effectiveness in
FM pain
Cyclobenzaprine
Muscle
relaxant (NE)
+
Pain, sleep
(poor long
term)
Off
Pramipexole
Dopamine
agonist
+
Pain, fatigue
Off
Limited population
studied
Sertraline
SSRI
±
Pain,
depression
Off
Compared versus
physical therapy
Venlafaxine
SNRI > SSRI
+
Pain,
depression,
anxiety
Off
Limited FM study
Medication
Mechanism
of Action
Atypical
antipsychotics
Dopamine
Cannabinoids
Efficacy in
Overall FM
Management
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
SSRI, selective serotonin reuptake inhibitor
No Evidence:
Medication Options in FM
(alphabetical order)
Medication
Mechanism of
Action
Rationale for
Use
Concern for Use
Benzodiazepines
GABA increase
Anxiety
Addiction
Side effects
NSAIDs
Prostaglandin
inhibition
Analgesia
NSAID-related side
effects
Opioids
Opioid receptor
agonists
Analgesia
Addiction
Side effects
Stimulants
(dextroamphetamine,
methylphenidate)
NE
Dopamine
Fatigue
Diversion
Abuse
Zopiclone
GABA
Sleep
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy;
NSAID, non-steroidal anti-inflammatory drug
-: no evidence for use/efficacy
Video 2
Video de-brief
Summary
Establish realistic treatment goals
Important to manage patient expectations
Chose medications that target the most
troublesome symptoms
Start low, go slow – reassure
Use polypharmacy with care
Opioids are controversial
Menu
Following this module, participants will be able to:
Differentiate the concepts of functional remission versus
full symptom remission
Establish realistic therapeutic goals with patients
Use interdisciplinary team resources to manage patients
with fibromyalgia (FM)
Objectives
Case Study
Patty is a 32-year-old patient in your practice
who was diagnosed with FM that appeared to
start after she slipped on some ice.
After communicating the diagnosis to her, you
referred her to a local FM lifestyle program.
She was also started on a medication targeting
sleep restoration, her most debilitating
symptom at presentation. She presents for
a follow-up visit.
Video 1
Questions
1. How do you monitor the effectiveness
of treatments?
2. What is the realistic endpoint of therapy
for FM? Is full remission of symptoms
a reasonable goal?
3. How do you explain or negotiate therapeutic
goals to patients?
4. How could you use an interdisciplinary team
(your own team or resources in your community)
to manage your patients with FM?
Take the time to answer each of the questions
Monitoring Treatment
Currently, there is no currently validated
acceptable tool for assessing response
to treatment
Consider evaluation of patients with FM
in these dimensions:
Pain
Fatigue
Sleep
Functionality (physical and psychological)
Mood
Functional versus Symptom Remission
Symptomatic remission is resolution of all
symptoms associated with the condition
Functional remission is improvement of symptoms
to the point where patients can maximize function
(vocational, interpersonal, social)
Although most patients with FM will not attain full
symptom remission in the short term, the natural
history of FM is more positive
Fate of Patients with FM
Reassure patients that FM is not progressive and
that symptoms remain stable over time1
50% were moderately to greatly improved
(3 year follow-up)2
• The baseline predictors for a favorable outcome:
younger age and less sleep disturbance2
Successful management requires an upbeat,
optimistic approach and EARLY initiation
of effective, individualized therapy
1. Kennedy et al. Arthritis Rheum. 1996;39:682-685.
2. Fitzcharles et al. J Rheumatol. 2003;30:154-159.
Strategy for Management
Explain the long-term nature of FM
Reassure the patient that it is
not life-threatening
Choose therapies that target the most
disabling symptom(s)
Emphasize functional improvements
Balance medication side effects
with improvement in function
Medications Options for FM (1)
(alphabetical order)
Medication
Mechanism
of Action
Efficacy in Overall
FM Management
Effect on
major
symptoms
Off/onLabel
Indication
Comments
Amitriptyline
(desipramine,
nortriptyline,
doxepin)
TCA
(NE > 5HT)
+
Pain, sleep,
anxiety
Off
FM dose < usual
antidepressant
dose
Poor long term
Cannabinoids
CB 1
receptor
agonist
+
Sleep
Off
Lack of
effectiveness in
FM pain
Cyclobenzaprine
Muscle
relaxant
(NE)
+
Pain, sleep
Off
Poor long term
Duloxetine
SNRI
+++
Pain,
depression,
anxiety
On
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant
Medications Options For FM (2)
(alphabetical order)
Medication
Mechanism of
Action
Gabapentin
2 binding:
↓neuronal excitation
Modafinil
Efficacy in
Overall FM
Management
Effect on major
symptoms
Off/on-Label
Indication
Comments
++
Pain, sleep,
anxiety
Off
Dopamine
NE
+
Fatigue
Off
Open label small
study
Pramipexole
Dopamine agonist
+
Pain, fatigue
Off
Limited population
studied
Pregabalin
2 binding:
↓neuronal excitation
+++
Pain, sleep,
anxiety
On
Sertraline
SSRI
++
Pain, depression
Off
Tramadol
Opioid agonist
SNRI
++
Pain
Off
Venlafaxine
SNRI > SSRI
+
Pain,
depression,
anxiety
Off
Compared versus
physical therapy
Limited FM study
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
SSRI, selective serotonin reuptake inhibitor
Video 2
Video de-brief
Summary
It is rare that treatment will result
in full symptom remission
Focus for therapy is to increase the level
of function, accepting some degree
of residual symptoms
Educate patients around realistic treatment goals
Where possible, quantify symptoms and level
of function
An interdisciplinary team can assist in education,
establishing and reinforcing treatment goals
For pharmacologic treatment:
start low, go slow!
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