Fibromyalgia

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

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

 

 


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Differential Diagnosis

 

 


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Best Tests

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

 

 


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Best Therapy

Drug Therapy

Diffuse Pain

  • Tricyclic antidepressants (TCAs)
    • Amitriptyline
      • Dose: 10 mg q.h.s. starting dose, escalating slowly to 50 mg q.h.s.
      • Cost/mo: $3
  • Cyclobenzaprine
    • Dose: 10 mg q.h.s.
    • Cost/mo: $49
  • Selective serotonin reuptake inhibitors (SSRIs)
    • Fluoxetine
      • Dose: 20–40 mg daily
      • Cost/mo: $16
    • Citalopram
      • Dose: 20–40 mg daily
      • Cost/mo: $40
  • Serotonin/noradrenaline reuptake inhibitors (SNRIs)
    • Duloxetine
      • Dose: 20–60 mg daily
      • Cost/mo: $100
  • Venlafaxine
    • Dose: 150–225 mg daily divided b.i.d.–t.i.d.
    • Cost/mo: $95
  • Combination therapy of TCA with SSRI or duloxetine
  • Antiepileptics (combined with antidepressants) for treatment of marked hyperalgesia and allodynia
    • Gabapentin
      • Dose: 300 mg q.h.s. to 600 mg t.i.d.; escalate over several weeks
      • Cost/mo: $30
    • Topiramate
      • Dose: 25–50 mg q.h.s. to 200 mg b.i.d.; escalate by 25–50 mg at weekly intervals
      • Cost/mo: $162
    • Tiagabine
      • Dose: 2–4 mg q.h.s. to 56 mg q.d. in two to four divided doses; escalate by 4–8 mg at weekly intervals
      • Cost/mo: $314
  • Adjunctive drug therapy
    • Anxiolytics
      • Benzodiazepines (clonazepam, temazepam)
      • Buspirone

Fatigue

  • Modafinil
    • Dose: 100–200 mg q.a.m.
    • Cost/mo: $186
  • SSRIs
  • Methylphenidate
    • Dose: 20–30 mg daily

Depression

  • SNRIs
    • Venlafaxine
    • Duloxetine
  • SSRIs
    • Fluoxetine
    • Citalopram
    • Multiple other

Nonpharmacologic Therapy

  • Aerobic exercise
  • Biofeedback and stress management
  • Yoga
  • Meditation
  • Psychological intervention
  • Support groups
  • Patient education

 

 


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Best References

Bennett RM: Rheum Dis Clin North Am 28:181, 2002

Goldenberg DL, et al: JAMA 292:2388, 2004

Wolfe F, et al: Arthritis Rheum 33:160, 1990


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

January 2006