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
- Chronic syndrome marked by the following:
- Generalized pain
- Increased sensitivity to pain
- Multiple defined tender points
- Second rib anteriorly
- Occiput
- Low cervical
- Trapezius midpoint
- Supraspinatus
- Lateral epicondyle
- Gluteal
- Greater trochanter
- Knee medial fat pad
- Fatigue
- Disturbed/nonrestorative sleep
- Female predominance
- May occur in children
- Frequently associated with self-assessed anxiety or
depression; multiple other somatic complaints also common (e.g., headache,
irritable bowel syndrome)
- Frequently coexists with organically defined disease
(e.g., rheumatoid arthritis, SLE)
Differential Diagnosis
- Rheumatoid arthritis, Sj�gren syndrome
- SLE
- Polymyalgia rheumatica
- Spondyloarthropathies
- Inflammatory myopathy
- Hypothyroidism
- Osteomalacia
- Cervical radiculopathy
- Multiple sclerosis
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
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
Depression
- SNRIs
- SSRIs
- Fluoxetine
- Citalopram
- Multiple other
Nonpharmacologic Therapy
- Aerobic exercise
- Biofeedback and stress management
- Yoga
- Meditation
- Psychological intervention
- Support groups
- Patient education
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
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