fibromyalgia

Question 1

• widespread pain & tenderness to touch that can migrate, wax & wane d/t abnormal sensory processing causing pain amplification at lest 3 months
• fatigue, sleep issues, etc.

Answer 1

FM

Question 2

3 triggers of FM

Answer 2

• acute pain
• infections– EBV, viral hep
• trauma– emotional & physical

Question 3

presentation of FM

Answer 3

• diffuse pain w/ morning stiffness, fatigue, paresthesias or sleep disorders
• cognitive difficulties
• exacerbation w/ weather changes

Question 4

how is FM diagnosed

Answer 4

WPI+ SSS = FS score; over 12 is needed for diagnosis; indicates severity of FM sx
over 3 months & affects at least 4 of 5 body regions
normal ESR/CRP, CBC

Question 5

what labs are needed for FM

Answer 5

• no specific labs– could do CBC and CRP at most
• no imaging or RF or ANA!

Question 6

1st line tx for FM

Answer 6

• patient education, exercise, CBT
• acupuncture, tai chai to complement

Question 7

1st pharmacologic tx to try for FM

Answer 7

amitriptyline 25 mg qhs

Question 8

• NT reuptake inhibitor & anticholinergic taken at low dose at night & titrated slowly (takes 1-3 wks for effect)
• effective for pain & sleep
• adr: cardiotoxicity, sedation, blurred vision, wt gain, anticholinergic effects
• CI: hypersensitivity, MAOI or cisapride use, recovery after MI
• caution w/ suicide, etc.

Answer 8

amitriptyline

no dose adjustment for renal or hepatic recommended

Question 9

• skeletal muscle relaxant that can cause drowsiness, dizziness, dry mouth with onset of 1 hr
• CI: hypersensitivty, MAOI use, heart dz
• caution in elderly, etc

Answer 9

cyclobenzaprine

Question 10

SNRI also used for eating disorders, etc that can cause nausea, diarrhea, dry mouth, anorexia, taken in the AM and good for pts w/ severe fatigue or comorbid depression
- CI: crcl under 30, childs pugh A,B,C, alcohol abuse
- avoid abrupt withdrawal

Answer 10

duloxetine

Question 11

• SNRI good for pain and fatigue used as alt to duloxetine
• CI: suicidal ideation, chronic liver dz

Answer 11

milnacipran

Question 12

• GBA analogue that inhibits excitatory NT release also used for partial seizures and neuropathic pain
• ADR: dizziness, drowsiness, wt gain, peripheral edema
• CI: hypersensitivity
• cauion– misuse, wean off; need to adjust for renal impairment

Answer 12

pregablin

Question 13

• GABA analog used for seizures and post herpetic neuralgia
• ADR: dizzness, drowsiness, wt gain
• CI: hypersensitivity
• caution– CNS dep., wean off; need dose adjustment for renal impaired

Answer 13

gabapentin

Question 14

opioid analogue NOT good in elderly

Answer 14

tramadol

Question 15

3 meds with no PROVEN efficacy for FM

Answer 15

tramadol or other opioids
NSAIDs (could try first for pain)
topical capsaicin

Question 16

2 most common combo tx for FM

Answer 16

• duloxetine + pregablin
• fluoxetine or duloxetine in AM + amitriptyline at bedtime