Fibromyalgia: A Medical Perspective
Fibromyalgia is a chronic pain disorder that is difficult to treat by traditional methods. There is no test that confirms this diagnosis, which is based upon the following clinical criteria:1 widespread musculoskeletal pain for at least 3 months and2 excess tenderness in at least 11 of 18 predefined anatomic sites, 9 on each side of the body.
Patients with fibromyalgia generally respond best to a multidisciplinary treatment program that incorporates MDs, NDs and non-physician providers. Most patients have had fibromyalgia for years and have consulted with many different specialists before the diagnosis is finally made. For patients to understand the rationale of prescription drug therapy and complementary approaches, the relationship of neurohormones to pain perception, fatigue, abnormal sleep, and mood disturbances should be discussed. Symptoms will wax and wane, but the pain and fatigue generally persist. Despite the presence of these chronic symptoms, it is reassuring that the majority of patients live normal, active lives.
There is no evidence that tissue inflammation is present in patients with fibromyalgia. Thus, it is not surprising that anti-inflammatory medications such as tramadol (Ultram), ibuprofen (Motrin) and meloxicam (Mobic), don’t work. Steroids are also ineffective and have the potential for adverse side effects. Patients with fibromyalgia are frequently treated with analgesics, despite no evidence of benefit. Overmedication is common in the treatment of fibromyalgia. A very significant problem is noncompliance with medications, reported in up to 50% of patients, primarily due to side effects and poor communication between physician and patient.
The following prescription medications are approved for the treatment of fibromyalgia. The first three are anti-depressants and the last is an anti-seizure medication.
- Amitriptyline (Elavil) at a dose of 5 to 10 mg at bedtime, though side effects such as dry mouth, constipation, fluid retention, weight gain, grogginess, and difficulty concentrating are common.
- Duloxetine (Cymbalta) at a dose of 20 mg in the morning. Common side effects are nausea, headache, and dry mouth in more than 40% of patients.
- Milnacipran (Savella) at a dose of 50 mg twice daily. Adverse effects including nausea, headache and constipation, leading to discontinuation in over 20 % of patients.
- Pregabalin (Lyrica) at a dose of 25 mg twice at bedtime and gradually increased to 150 mg twice daily. Dizziness and somnolence were the most common adverse effects.
I use the following general guidelines for pharmacologic management:
- In general, drugs should be started at low doses and built up slowly.
- A low dose of amitriptyline (Elavil) at nighttime should be considered as initial therapy. Use may be limited by adverse side effects, especially in the elderly.
- In those with sleep problems, I start with pregabalin (Lyrica) at night.
- In those who have more exhaustion, I prefer duloxetine (Cymbalta) or milnacipran (Savella) at breakfast.
- Some patients do better with a low dose of Cymbalta in the morning with a low dose of Lyrica in the evening.
There are numerous non pharmacologic approaches that can be effective.
- Cardiovascular exercise, including water therapy, at least 30 minutes, three times per week. Patients generally think their symptoms worsen with exercise so treatment must begin slowly
- Psychological treatments including cognitive behavioral therapy, mindfulness-based treatment, relaxation and biofeedback
- Oriental medicine including acupuncture, Tai Chi and yoga
- Musculoskeletal therapy with chiropractic or massage, and therapeutic ultrasound
- Naturopathic approaches as discussed by Dr. Sinsheimer
I advise a multidisciplinary approach to treatment. The specific interventions should be individualized based upon patient preference and available resources. So it is critical that patients have a good relationship with their health care provider.
Dr. Thomas Reynolds is a board-certified internist and oncologist. His practice focuses on integrative and palliative care. Dr. Reynolds can be reached at 760.773.3200