Fibromyalgia

Pt with h/o IBS, PTSD, depression presents with chronic pain, fatigue, and sleep disturbances. Pt reports diffuse muscle pain/tenderness and difficulty concentrating that is affecting her quality of life. Muscle tenderness, joint stiffness on exam.

• Evaluate symptoms per American College of Rheumatology 2010 Diagnostic Criteria

• Obtain CBC, TSH

• Consider ESR, CRP, rheumatoid factor to r/o connective tissue disorder

• Treatment

  • Start CBT

  • Medication for pain, sleep disturbance, fatigue (choose one of the following)

    • Amitriptyline 25 mg qhs

    • Duloxetine 30 mg daily x1 week, then increase to 60 mg daily

    • Milnacipran: 12.5 mg on day 1, 12.5 mg bid on days 2-3, 25 mg bid on days 4-7, then 50 mg bid

  • Additional agents

    • Cyclobenzaprine (Flexeril) 15 mg daily for pain, sleep quality

    • Pregabalin (Lyrica) 75 mg BID for pain

  • Consider alternative therapies, i.e. massage, hydrotherapy, acupuncture

  • Consider rheumatology consult

• Counseling

  • Pt advised to engage in aerobic exercise for 30 min 3x per week

  • Pt counseled realistic expectations for pain control

  • Pt counseled about sleep hygiene

  • Pt encouraged to keep symptom diary

  • Close follow-up; schedule appointment in 4 weeks

Notes

• 30% of fibromyalgia patients have irritable bowel syndrome

• 45% of fibromyalgia patients meet PTSD criteria

• Tender point site testing is no longer used in diagnosis

• Do not test for Lyme in the absence of appropriate history and exam findings

• Write non-pharmacologic therapies as prescriptions

• NNTs for commonly used medications: Amitriptyline (4), duloxetine (9), milnacipran (11)