Improving patient outcomes in Fibromyalgia

Contents

• Introduction
• Understanding Fibromyalgia
• Mechanisms of Pain*
• The Role of Stress*
• Beyond Pain*
• Comorbidity*
• Irritable Bowel Syndrome*
• Restless Legs Syndrome*
• Neuropsychiatric Comorbidities and Cognitive Dysfunction*
• Sleep Disorders*
• Making the Diagnosis*
• Diagnostic Criteria for Fibromyalgia*
• Patient History*
• Fibromyalgia vs Myofascial Pain*
• Review of Systems and Physical Examination*
• Treatment Considerations*
• Pharmacotherapy*
• Pregabalin*
• Gabapentin*
• Tricyclic Antidepressants and Cyclobenzaprine*
• Selective Serotonin Reuptake Inhibitors (SNRIs)*
• Duloxetine*
• Milnacipran*
• Pramipexole*
• Tramadol*
• EUCLAR Guidelines for Pharmacologic Treatment of FM*
• Nonpharmacologic Treatment*
• Summary*
• Case Studies*
• Case 1*
• Case 2*
• References*
• Additional Information*

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Target Audience

Physicians, nurses, pharmacists, and physician assistants.

Purpose Statement

The purpose of this activity is to increase knowledge of practitioners, enhancing their understanding of the mechanisms associated with fibromyalgia. The altered pain response associated with fibromyalgia will be positioned to achieve more postitive clinical outcomes in the patients with fibromyalgia that they treat and manage.

Learning Objectives

After completing this activity, participants will be able to:

• Review classes of traditional and newer medications used to treat fibromyalgia
• Identify appropriate screening tools and strategies to determine fibromyalgia
• Describe patient types and conditions affecting treatment decisions
• Choose treatment approaches in relation to patient profiling

Introduction

Fibromyalgia (FM) is characterized by chronic widespread pain and tenderness on palpation.¹ It has been estimated to afflict 3.4% to 10.5% of women and 0.5% of men.^{2, 3} The prevalence of the disorder increases in an age-related manner with as few as 0.9% of women between the ages of 18 and 29 having the disorder. Thereafter, prevalence rises quickly with respect to age and is estimated to affect 2.0% of women between the ages of 30 and 39 and 5.6% and 7.4% of women in the 50-59 and 70-79 age groups, respectively. Moreover, FM is 6 times more prevalent in women than in men from the age of 50 onward.³

While the diagnostic criteria for FM are straightforward and well documented,¹ FM is in fact a complex condition that is associated with a broad range of symptoms and comorbidities beyond the experience of chronic widespread pain and debilitating fatigue.^1,4 A diagnosis of FM is not one of exclusion,5 but does rely on thorough clinical investigation, listening skills, and appropriate application of established diagnostic criteria.⁵

Among the challenges of treating FM is the fact that the pain associated with the disorder is often refractory to standard clinical interventions. Consequently, patients frequently experience emotional distress, disability, and diminished quality of life. Indeed, results of a recent study that evaluated the impact of moderate-to-severe FM pain on patients’ health-related quality of life (HRQOL) revealed that HRQOL was significantly worse (P<.05) than that of normal individuals in terms of physical functioning, bodily pain, general health, vitality, social functioning, role-emotional function, mental health, and physical and mental component summaries. Patients with FM also had HRQOL at least one standard deviation (SD) worse than those with congestive heart failure (CHF), along with sleep impairment scores that were almost one SD above those in other chronically ill
adults.⁶

A diagnosis of FM can be elusive given the complexity of symptoms associated with the
disorder. Because patients frequently have comorbid medical conditions, they may consult
a range of specialists to address symptoms specific to certain organ systems without
receiving a diagnosis for what may ostensibly be their overarching condition, ie, FM. The
prevalence of medical specialization may therefore represent a prominent obstacle to
receiving proper treatment inasmuch as each specialist that the patient consults is likely
to focus on a single system or condition. For example, a rheumatologist may refer patients
with musculoskeletal complaints to a gastroenterologist to address gastrointestinal (GI)
complaints or a psychiatrist to evaluate neuropsychiatric symptoms. An ideal situation
would therefore be one in which a primary care provider (PCP) or other “point person”
would be able to oversee a patient’s broader clinical picture and take responsibility for
comprehensive disease management.

In light of the foregoing, optimization of clinical outcomes in patients with FM
ostensibly relies on treatment of the whole patient and implementation of evidencebased
pharmacologic and nonpharmacologic interventions that target FM and comorbid
conditions. The remainder of this monograph will therefore discuss FM in terms of both
pain and symptoms beyond pain, the means by which to establish proper diagnoses, and
considerations for comprehensive assessment and management.

Understanding Fibromyalgia

Mechanisms of Pain

It appears likely that the primary pathophysiological abnormality in FM is dysfunction of
pain-modulatory systems. However, it remains to be determined whether this dysfunction
is the consequence of a unique pathophysiological process or is perhaps due to a
confluence of other chronic pain conditions of unknown origin.⁷

While this insight has not resulted in a widely accepted explanation of the
pathophysiology of FM pain, currently available evidence indicates that disruption
of somatosensory information processes is the most likely explanation for increased
perception of pain. Thus, disruption of any of 3 distinct processes that participate
in somatosensory perception could play a role. These processes include transfer of
somatosensory information from the periphery to the central nervous system (CNS);
supraspinal processing of somatosensory information received from the periphery;
and efferent flow of information via descending spinal tracts that filter the flow of
somatosensory input. Accordingly, potential contributors to the development and expression of chronic, widespread pain include peripheral pain generators, peripheral
sensitization, failed descending inhibition, enhanced descending facilitation, spinal
sensitization, and supraspinal imbalances (Figure 1).⁷

Patients with FM may have other conditions that are associated with pain. Similarly,
patients with other existing pain conditions may have FM as a comorbid condition
(sometimes referred to as “secondary FM”). For example, rheumatic diseases are a
common comorbidity for patients with FM as established by results of a study whose goal
was to establish criteria for FM diagnosis. Among patients evaluated, 42% of those with
FM had concurrent inflammatory arthritis, including rheumatoid arthritis, polyarthritis
and systemic disorders, and systemic lupus erythematosus. Similarly, 30.7% of those with
FM had axial skeletal syndromes (low back pain and neck pain syndromes).¹

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