Best Dx/Best Rx: Fibromyalgia

From: Subject: Best Dx/Best Rx: Fibromyalgia Date: Wed, 3 Jun 2009 21:39:52 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_01FB_01C9E493.D3E2EE80" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_01FB_01C9E493.D3E2EE80 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1513.htm Best Dx/Best Rx: Fibromyalgia

Fibromyalgia

John Buckner Winfield, M.D.
University = of North=20 Carolina School of Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

Chronic syndrome marked by the following: =
- Generalized pain
- Increased sensitivity to pain
- Multiple defined tender points
  - Second rib anteriorly
  - Occiput=20
  - Low cervical
  - Trapezius midpoint
  - Supraspinatus
  - Lateral epicondyle
  - Gluteal=20
  - Greater trochanter
  - Knee medial fat pad
- Fatigue=20
- Disturbed/nonrestorative sleep =
Female predominance
May occur in children
Frequently associated with self-assessed = anxiety or=20 depression; multiple other somatic complaints also common (e.g., = headache,=20 irritable bowel syndrome)
Frequently coexists with organically defined = disease=20 (e.g., rheumatoid arthritis, SLE)

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Differential = Diagnosis

Rheumatoid arthritis, Sj=F6gren syndrome =
SLE=20
Polymyalgia rheumatica
Spondyloarthropathies=20
Inflammatory myopathy (including statin = myopathy)=20
Hypothyroidism=20
Hepatitis C=20
Osteomalacia=20
Cervical radiculopathy
Multiple sclerosis

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Best=20 Tests

Physical examination objectively normal in = uncomplicated=20 disease; abnormal physical or neurologic findings suggest comorbid = disorder or=20 alternative diagnosis
No specific laboratory abnormalities
Perform limited screening for comorbid = disorders and for=20 other disorders that cause pain and fatigue
- Antinuclear antibody
- CBC
- ESR or C-reactive protein
- TSH=20
- Creatine kinase
- AST, ALT
- Urinalysis

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Best=20 Therapy

Nonpharmacologic=20 Therapy=20

Aerobic exercise
Biofeedback and stress management
Yoga=20
Meditation=20
Psychological intervention
Support groups=20
Guide patients to reliable sources of = information=20
- Arthritis Foundation=20
- American College of Rheumatology=20
- Fibromyalgia Society
Patient education=20
- Disorder is in perception of pain=20
- The pain as perceived is real =
Patient takes active role in managing = symptoms=20

Drug Therapy

Diffuse Pain=20

Tricyclic antidepressants (TCAs)
- Amitriptyline=20
  - Dose: 10 mg q.h.s. starting dose, = escalating slowly=20 to 50 mg q.h.s.
  - Cost/mo: $9
Cyclobenzaprine=20
- Dose: 10 mg q.h.s.
- Cost/mo: $49
Selective serotonin reuptake inhibitors = (SSRIs)
- Fluoxetine=20
  - Dose: 20=9640 mg daily
  - Cost/mo: $16
- Citalopram=20
  - Dose: 20=9640 mg daily
  - Cost/mo: $40
Serotonin/noradrenaline reuptake inhibitors = (SNRIs)=20
- Duloxetine
  - Dose: 20=9660 mg daily
  - Cost/mo: $100
- Venlafaxine=20
  - Dose: 150=96225 mg daily divided = b.i.d.=96t.i.d.
  - Cost/mo: $95
Combination therapy of TCA with SSRI or = duloxetine=20
Antiepileptics (combined with antidepressants) = for=20 treatment of marked hyperalgesia and allodynia
- Gabapentin
  - Dose: 300 mg q.h.s. to 600 mg t.i.d.; = escalate over=20 several weeks
  - Cost/mo: $30
- Topiramate=20
  - Dose: 25=9650 mg q.h.s. to 200 mg b.i.d.; = escalate by=20 25=9650 mg at weekly intervals
  - Cost/mo: $162
- Tiagabine=20
  - Dose: 2=964 mg q.h.s. to 56 mg q.d. in two = to four=20 divided doses; escalate by 4=968 mg at weekly intervals
  - Cost/mo: $314
Adjunctive drug therapy
- Anxiolytics=20
  - Benzodiazepines (clonazepam, temazepam) =
  - Buspirone =

Fatigue=20

Modafinil
- Dose: 100=96200 mg q.a.m.
- Cost/mo: $186
SSRIs=20
Methylphenidate
- Dose: 20=9630 mg daily =

Depression=20

SNRIs=20
- Venlafaxine
- Duloxetine
SSRIs=20
- Fluoxetine=20
- Citalopram=20
- Multiple other

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Best References

Bennett RM: Rheum Dis Clin North Am 28:181, 2002 = [PMID=20 12122913]

Goldenberg DL, et al: JAMA 292:2388, 2004 [PMID=20 15547167]

Wolfe F, et al: Arthritis Rheum 33:160, 1990 = [PMID=20 2306288]

The author has been a member of the = speakers'=20 bureau of Wyeth and a member of the advisory committee of = Sanofi-Aventis, Inc.=20

July=20 2006