Management of Fibromyalgia Materials

BEYOND PAIN AND TIREDNESS: MANAGEMENT OF FIBROMYALGIA

Kimberly Valenta, MD

Kimberly Valenta is a freelance medical writer and editor. She studied chemistry at Mount Holyoke College and medicine at Northwestern University. After completing her anesthesiology residency, she joined the faculty at Stanford University, where she cared for patients and taught medical students and residents. In 2020, she transitioned to writing and editing full-time. She holds a certificate in medical writing and editing from the University of Chicago and is an active member of the American Medical Writers Association.

Pamela Sardo, PharmD, BS

Pamela Sardo is a freelance medical writer, pharmacist licensed in 3 states, and the founder/principal at Sardo Solutions. She received her BS from the University of Connecticut and a PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, pharmaceutical manufacturing, and managed healthcare across broad therapeutic classes and disease states.

Topic Overview

Fibromyalgia is a central chronic pain syndrome that is characterized by increased pain perception, widespread pain in multiple areas of the body, fatigue, poor sleep quality, and cognitive disturbances. Fibromyalgia affects people of all ages but is mostly seen in adults, and there is no known cure. Despite a 2–4% global prevalence, it is poorly understood and lacks consistent diagnostic criteria and management. This course discusses the attitudes of healthcare professionals toward fibromyalgia patients and how the disease typically presents, current theories on its pathophysiology, the suggested diagnostic workup, and recommendations for symptomatic management. This information can assist healthcare professionals in advocating on behalf of patients with fibromyalgia and improve health outcomes for them.

Accreditation Statement

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-24-160-H01-P

Pharmacy Technician  0669-0000-24-161-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: November 9, 2024 Expiration Date: November 9, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians.

How to Earn Credit: From November 9, 2024, through November 9, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Understand the meaning of a central pain syndrome

Recognize symptoms of fibromyalgia

Identify treatment options for the management of fibromyalgia

Formulate a collaborative multidisciplinary plan of care for a patient with fibromyalgia

Disclosures

The following individuals were involved in developing this activity: Kimberly Valenta, MD, and Pamela Sardo, PharmD, BS. Pamela Sardo and Kimberly Valenta have no conflicts of interest or financial relationships regarding the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

Beyond Pain and Tiredness: Management of Fibromyalgia Introduction

Fibromyalgia is a central chronic pain syndrome that is characterized by increased pain perception, widespread pain in multiple areas of the body, fatigue, poor sleep quality, and cognitive disturbances. The root cause of this central chronic pain syndrome is unknown, and there is no known cure. This course discusses the attitudes of healthcare professionals toward fibromyalgia patients and how the disease typically presents, current theories on its pathophysiology, the suggested diagnostic workup, and recommendations for symptomatic management. This information can assist healthcare professionals in advocating on behalf of patients with fibromyalgia and improve health outcomes for them.

Clinician and Patient Attitudes Toward Fibromyalgia

With no clear understanding of fibromyalgia, the attitude of physicians toward fibromyalgia patients is not always supportive.1 This attitude causes some patients to fall into a “culture of fibromyalgia,” which can be a self- fulfilling prophecy in which patients engage in counterproductive behavior.1 Patients’ counterproductive behavior can make clinicians averse to patients, believing they are unwilling to help themselves. This aversion has been called “fibroism,”1 and finds support in medical studies on attitudes toward fibromyalgia patients.1-3

A 2012 study of 1622 experienced physicians in Europe, Mexico, and South Korea reported that more than half felt their training in fibromyalgia was inadequate and that they found fibromyalgia difficult to diagnose.2 Approximately one-third did not feel confident in their ability to develop a treatment plan and considered themselves to lack sufficient knowledge about fibromyalgia.2

A 2010 Canadian study revealed that 23% of general practitioners considered fibromyalgia patients as malingers, or people who feign illness, and 76% considered managing patients with fibromyalgia to be time consuming and frustrating.1

One would hope that attitudes would have changed since then, but a 2023 literature review confirmed that challenges in diagnosis, management, and patient-physician relationships remain. For instance, 38% of patients admitted to delaying their doctor visits because they feared their symptoms would not be taken seriously.3

Delays in diagnosis contribute to excessive medical expenses, unnecessary tests and treatments, a loss of trust in the healthcare system, emotional distress, and strained personal and professional relationships. Furthermore, a lack of validation by healthcare professionals can contribute to the degree of pain.4

There is no cure for fibromyalgia, so management is focused on addressing its symptoms.3 A multidisciplinary approach helps reduce symptoms.5

Symptoms of Fibromyalgia

The hallmark symptoms of fibromyalgia are persistent and widespread non-inflammatory musculoskeletal pain, fatigue, impaired cognitive function, and nonrestorative sleep.5,6 Symptoms such as migraine or tension headache, digestive symptoms (irritable bowel), morning stiffness, and irritable or overactive bladder are also common. Individuals may demonstrate a negative affect (negative internal mood), with a tendency towards catastrophizing, anxiety, neuroticism, and depression.5,6

Pain is persistent (lasting longer than 3 months) and widespread (present in 4 out of 5 regions).5,6 Musculoskeletal pain in the shoulders, arms, lower back, buttocks, and thighs is typical. The pain is often described as throbbing and achy. The areas are tender and hypersensitive (hyperalgesia),

and light touch or pressure may provoke pain (allodynia).6 The pain cannot be explained by injury or inflammation and is thought to be due to altered sensory processing.5,6

The presentation can be complicated by pain from other causes, such as arthritis, migraine, and irritable bowel. Medical terms that may be used to describe the pain include the following:6

Allodynia: Pain resulting from a non-noxious stimulus to normal skin (e.g., pain from a blood pressure cuff on the arm)

Hyperalgesia: Abnormally increased pain in response to a noxious stimulus (e.g., exaggerated pain response to a fingerstick)

Somatic pain: (1) Pain in the body wall (e.g., musculoskeletal, skin) that is typically well-localized and may be described as throbbing or aching, and (2) body pain in general

Visceral pain: Pain from within a body cavity (e.g., abdominopelvic, thoracic) that is more difficult to localize and tends to be described as colicky or squeezing

Individuals with fibromyalgia report feeling fatigued, physically and emotionally. They feel exhausted regardless of how much they rest or sleep. They may also experience additional sensitivity to light and sound.

Impaired cognitive function, memory loss, and decreased mental alertness are common experiences for individuals with fibromyalgia. They can lead to “fibro fog” and can contribute to feelings of anxiety and depression.7,8 For many individuals, fibro fog is the symptom that is the most debilitating.9

Nonrestorative sleep is a common concern for individuals with fibromyalgia.9 They tend to sleep fewer hours each night and wake up feeling stiff, weak, and tired.9

Symptoms are often exacerbated by physical and emotional stress, including disrupted sleep and excessive physical activity for their fitness level.9 Weather changes can also trigger symptoms.6 This constellation of symptoms is characteristic of central pain syndromes.

Central Pain Syndrome and Fibromyalgia

Central pain syndrome is characterized by increased pain perception throughout the body. The root cause of this central pain syndrome is unknown. The pain occurs without identifiable nerve or tissue damage. Many factors contribute to the development of fibromyalgia in a unique manner: genetic predisposition, personal experiences, emotional-cognitive factors, and psychological ability to cope with stress.10 It may result from persistent neural dysregulation, and patients feel more pain than typically expected based on nociceptive input. Central nervous system alterations in pain and sensory processing are present in fibromyalgia.10 There may be a deficiency in endogenous analgesia,11 and it can be triggered or aggravated by infections and emotional and physical trauma.10 Early and abnormal activation of the pain system, as well as an impaired antinociceptive system, contribute to the development of clinical pain.12

Fibromyalgia presents with problems processing pain, and patients experience prolonged and enhanced pain. Abnormalities include elevated levels of neurotransmitters, like glutamate and substance P, decreased serotonin and norepinephrine, dysregulation of dopamine, and alteration of endogenous brain opioids.13

Potentiation of serotonin and noradrenaline (also known as norepinephrine) is required to produce effective analgesia.14 Serotonin modulates pro-nociceptive and anti-nociceptive descending effects on central pain pathways from the brainstem.14 Noradrenaline has an antinociceptive impact. Therefore, when considering treatment options for patients suffering from fibromyalgia, drugs that inhibit the reuptake of serotonin and noradrenaline are considered. In summary, autoimmunity,

neuroinflammation, and small fiber neuropathy are considerations in pathophysiology and treatment decisions.

Epidemiology of Fibromyalgia

Fibromyalgia is typically estimated to have a worldwide prevalence of 2- 4%, though some researchers believe this number to be an underestimate due to challenges in diagnosis. Fibromyalgia is a clinical diagnosis without objective markers, and prevalence statistics vary depending on the diagnostic criteria used.6,15

It is more prevalent in females than males. Recent studies suggest that females make up ≤ 60% of total cases.16 Given the high enrollment of White participants and low enrollment of other races in fibromyalgia studies, prevalence according to race is unknown.15 Prevalence increases with age, peaking in the 7th decade of life.17

The first diagnostic criteria for fibromyalgia were published in 1990 by the American College of Rheumatology (ACR). The 1990 ACR criteria focused on pain symptoms, with the two primary criteria being:17

A history of widespread pain for at least 3 months

Pain in at least 11 of 18 tender points (allodynia) on digital palpation (with an approximate force of 4 kg)

The ACR updated its diagnostic criteria in 2010. The ACR 2010 criteria does not include tender point assessment but rather uses the following two assessments:6,17

Widespread Pain Index (WPI), which counts the number of areas in the body where the patient experienced pain over the past week

Symptom Severity Scale (SSS), which assesses the following symptoms:18

Fatigue

Waking unrefreshed

Cognitive symptoms

Somatic symptoms in general, which included a broad range of afflictions from hair loss and change in taste to irritable bowel syndrome and painful urination

In 2011, modifications were proposed for the 2010 criteria to more narrowly define the somatic symptoms (modified 2010 criteria) and make it possible for individuals to take the assessment and self-diagnose. Somatic symptoms were limited to headaches, pain or cramps in the lower abdomen, and depression within the past 6 months.6,17

A 2015 UK study compared the diagnostic criteria for 1990, 2010, and 2011. In the 1,604 participants, the prevalence of fibromyalgia was found to be:17

1.7% based on the ACR 1990 criteria, with a female:male ratio of 13.7:1

1.2% based on the ACR 2010 criteria, with a female:male ratio of 4.8:1

5.4% based on the modified 2010 criteria, with a female:male ratio of 2.3:1

The higher female prevalence in the 1990 criteria is suspected to be caused by the subjective assessment of tender points. The higher total prevalence in the patient-administered modified 2010 criteria is believed to capture the negative effect of patients.

In 2016, new criteria were proposed that combined the ACR 2010 criteria with the modified 2010 criteria, allowing the criteria to be applied by physicians or patients. These are the criteria that are used today. Current diagnostic criteria do not consider psychological, environmental, or sociocultural factors, even though these play a significant role in the onset and management of the condition.6

In summary, fibromyalgia is diagnosed on clinical criteria, many of which are self-reported and affected by societal-cultural norms. The move from the 1990 criteria to later criteria acknowledged the multifactorial nature of the condition by considering non-pain features, but some argue that additional factors should be added to the criteria. The perception of fibromyalgia as a disease that affects women is likely exaggerated. As our understanding of fibromyalgia grows, diagnostic criteria will hopefully become more objective, with improved sensitivity and specificity. Until that happens, the true prevalence of the disease remains speculative.

Fibromyalgia’s Clinical Presentation and Diagnostic Workup

Fibromyalgia is difficult to diagnose because the presentation can be confusing at first.5,6 Symptoms like forgetfulness, poor sleep, musculoskeletal pain, and fatigue can point to many different conditions. Patients may also not initially report widespread pain but focus on one area on the day of the clinic visit.5,6 The situation is often further complicated by the presence of additional symptoms, such as nausea, urinary frequency, and headache, resulting in what overwhelmed physicians call “a positive review of systems.”

To diagnose fibromyalgia, the clinician first needs a high level of suspicion that fibromyalgia is on the differential. Identifying risk factors and associated conditions can encourage the clinician to assess for fibromyalgia specifically.

Risk factors associated with fibromyalgia include the following:9

A family history of the disease (first-degree relative)

Traumatic childhood experiences, including abuse, serious illness, or accident

Prolonged psychological stress at home or work

Sleep disorder

Other conditions that may be present along with fibromyalgia include:

Psychiatric conditions:19

Major depressive disorder

Anxiety

Borderline personality disorder

Obsessive-compulsive personality disorder

Post-traumatic stress disorder

Other central pain syndromes:20

Irritable bowel syndrome

Interstitial cystitis

Chronic fatigue syndrome

Tension or migraine headaches

Temporomandibular disorder

Gulf War Syndrome

Vulvodynia

Other chronic pain conditions:20

Ankylosing spondylitis

Osteoarthritis

Rheumatoid arthritis

Systemic lupus erythematosus

Diabetes mellitus

Inflammatory bowel disease

Endometriosis

Hypothyroidism

Diagnosing fibromyalgia does not usually require a specialist. Clinicians can use the 2016 Revisions to the 2010/2011 fibromyalgia criteria. In case of doubt, a referral can be made to a rheumatologist, neurologist, or pain specialist. Diagnosing fibromyalgia in adults may be done using Tables 1 through 3.21

Table 1

Diagnosing Fibromyalgia in Adults

Table 2 Widespread Pain Index (WPI)

Table 3 Symptom Severity Scale

Indicate the level of severity over the past week	No problem	Mild Problem	Moderate Problem	Severe Problem
Points	0	1	2	3
Fatigue
Waking unrefreshed
Trouble thinking or remembering
Indicate whether you’ve had any of these symptoms			Point = 0	Point = 1
Headache			No	Yes
Lower abdominal pain or cramps			No	Yes
Depression			No	Yes
Total all points (out of 12)

Fibromyalgia is not a diagnosis of exclusion. It frequently coexists with other chronic pain conditions, such as rheumatoid arthritis, systemic lupus erythematosus, or ankylosing spondylitis. Despite physical examination, laboratory testing, and imaging not being required for diagnosis of fibromyalgia, they are usually performed to rule out other conditions on the differential diagnosis.

Two additional diagnostic criteria assessments, the modified 2019 FAS and AAPT criteria, were developed after the 2016 criteria. However, studies have shown lower sensitivity, specificity, and diagnostic accuracy, so the 2016 criteria continue to be recommended.22

Lastly, diagnostic uncertainty remains a challenge in many cases. Sometimes, symptoms fluctuate, resulting in a below-threshold score, or multiple conditions impact the interpretation of the results and blur the picture. The key is to communicate any diagnostic dilemmas with the patient, share important clinical signs and symptoms the patient should watch for to help direct the diagnosis and agree on managing the symptoms despite the lack of a formal diagnosis.

Pharmacologic Management of Fibromyalgia

The American Pain Society and European League Against Rheumatism (EULAR) have published treatment guidelines for fibromyalgia.23 The recommendations include four broad drug classes: 1) serotonin- norepinephrine reuptake inhibitors (SNRIs), 2) selective serotonin reuptake inhibitors (SSRIs), and 3) tricyclic antidepressants (TCAs), and 4) antiepileptic drugs (AEDs).23,24

The Food and Drug Administration (FDA) approved duloxetine, pregabalin, and milnacipran for the treatment of fibromyalgia.25-27 These three drugs have shown similar potency in alleviating pain, but their potential to manage other symptoms differs considerably. Their different pharmacodynamic and safety profiles make the initial choice an individualized decision.27

Treatment should focus on patient education, fitness, pharmacotherapy, and psychotherapy.10 The approach to patient care should be symptom-based and stepwise, establishing shared goals with the patient.10

In some cases, the efficacy of prescribed medications for fibromyalgia may decrease over time. In these cases, patients should be educated to wean off the prior medication gradually, and new treatments should be initiated slowly. A trial-and-error approach may be needed. Table 4 mentions commonly prescribed agents for individuals presenting with fibromyalgia.

Table 4

Common Agents Prescribed for Patients with Fibromyalgia23-27,29-40

*Review full prescribing information for each agent for comprehensive safety and efficacy data

Reinforcing the dose titration is an important patient counseling opportunity. Auxiliary labels may be placed to remind patients that the dose has changed as titration or tapering occurs.

Individuals with fibromyalgia may self-medicate with acetaminophen, aspirin, ibuprofen, or naproxen.41 Patients may also receive prescriptions for opioids. These are not recommended due to the risk of dependence and tolerance. Collaboration with a pain specialist may be helpful.

Pharmacy team members should monitor individuals with fibromyalgia for drug interactions and patient reports of side effects. There are ongoing opportunities to counsel patients. It is important to be empathetic and reassure the patient that fibromyalgia is a real disease.

Patients can be educated to report any new symptoms after starting a new medication. Emphasis should be placed on taking medication exactly as the prescriber directed and not stopping the medication abruptly.

Pharmacy technicians are usually the first staff to encounter patients in a pharmacy department. They are perfectly positioned to refer questions from these complex patients to the pharmacist. Pharmacy technicians will accurately process the prescriptions for fibromyalgia and double-check the medication strength on the prescription as prescribers advise dose increases over time to reach optimal symptom relief or dose decrease when tapering. Pharmacy technicians are critical in ensuring appropriate auxiliary labels, including drowsiness warnings, are placed on prescription bottles. Due to comorbidities, remain vigilant for computer drug interaction alerts.

Nonpharmacologic Management and Interprofessional Collaboration

Nonpharmacologic management is an important component in achieving pain reduction and quality of life improvement in individuals with fibromyalgia. They include lifestyle changes through exercise therapy and other nonpharmacologic treatments with various degrees of success, such as cognitive behavioral therapy (CBT), meditation, and acupuncture.

Exercise therapy is strongly recommended for the management of fibromyalgia.42-44 Individuals should start at a low level and gradually increase the duration and intensity over time. Low-impact aerobic exercise and strength training have been found to be beneficial.42-44 Suggested activities include swimming, yoga, water exercises, biking, walking, dancing, free weightlifting, and body weight resistance exercises.42

Patients may need the support of an exercise physiotherapist or physical therapist to get started because physical activity that is too strenuous may cause increased pain. Patients with fibromyalgia also benefit from ongoing encouragement and support to continue with an exercise program. Studies have found improvement in symptoms with as little as 20 minutes per day, 2 to 3 times per week.43

Education about fibromyalgia is also important. Patients who understand what central pain is are more equipped to explain their condition to others and advocate for themselves. They see how different actions influence their symptoms and feel more empowered to make changes and stick with them. Not only does this help with symptom management, but it also improves their relationships with family, friends, employers, and the medical community. Joining a support group, either in-person or online, is a great way for patients to learn more and find support.

Many other nonpharmacologic therapies have been tried. On average, studies have shown only weak evidence for any of them. For example, although CBT has been shown to be statistically significant in the treatment of pain and disability in people with fibromyalgia, it has not been shown to be clinically significant.42 This means that the numbers are statistically sound, but the differences in pain and disability are insufficient to be meaningful to the patient.42

That said, responses vary, and patients should feel comfortable trying different therapies, assuming they are affordable, to see what might work for them. For example, they might choose to:45

Participate in meditative movement therapies, such as tai chi, restorative yoga, and qigong

Seek out a mental health professional to pursue psychoanalysis or behavior therapy

Try different sleep routines and techniques, or work with a sleep specialist

Meet with a registered dietician to consider diets that reduce oxidative stress

Try acupuncture with a certified acupuncturist

Get regular massages by a massage therapist familiar with fibromyalgia

Work with a pain specialist who can perform transcranial electric stimulation or transcranial magnetic stimulation

Fibromyalgia is a chronic pain condition without a cure. Pharmacologic and nonpharmacologic management can reduce symptom burdens but not eliminate them. A good relationship between the patient and the care team can help them manage their expectations and develop self-efficacy.

Fibromyalgia Patient Case

A 30-year-old African American woman with a past medical history of hypertension, asthma, gastroesophageal reflux, migraines, obesity, and obstructive sleep apnea presented for evaluation of myalgia.46 Symptoms began in the prior year. She experienced dysphagia, generalized muscle tenderness, and tender neck lymphadenopathy.

As Figure 1 diagrams the case, remember that polymyalgia rheumatica is uncommon in young patients, and erythrocyte sedimentation rate and C- reactive protein are not normally elevated in fibromyalgia. The complex patient journey continues in Figure 1 below.

Figure 1

Difficult Patient Journey to Fibromyalgia Diagnosis46

*polymyalgia rheumatica (PMR) #erythrocyte sedimentation rate (ESR)

+c-reactive protein (CRP)

^magnetic resonance imaging (MRI)

Summary and What’s Next

A cure and single treatment for fibromyalgia remain elusive. Symptoms are varied, and pain severity and physical function are significantly impacted by fibromyalgia. Anxiety, stress, and depression exacerbate the condition.

Research is continuing to deepen our understanding of fibromyalgia. Because an estimated 65-99% of patients with fibromyalgia experience sleep disorders, a study is underway to examine the relationship between central sensitization chronotype (tendency to sleep at a certain time) and its relationship with pain intensity, disability, and quality of life.47

Another clinical trial is comparing the effects of placebo, and 500mg of once-a-day metformin on the improvement of hyperalgesia and other symptoms in patients with fibromyalgia.48

Patients presenting with fibromyalgia suffer in many ways. Pharmacy professionals' participation within an interprofessional team facilitates and supports comprehensive and multidisciplinary management of these complex patients to help patients optimize outcomes.

Course Test

Which of the following is associated with physiologic abnormalities in processing pain in individuals with fibromyalgia?

Elevated levels of glutamate and substance P

Elevated levels of serotonin and norepinephrine

Optimal regulation of dopamine

Optimal endogenous brain opioids

Which characteristic is least likely to be associated with central chronic pain syndrome?

Increased pain perception

Localized pain in a single area

Fatigue, poor sleep quality

Cognitive disturbances

Which choices below most accurately describe central pain syndromes other than fibromyalgia?

Irritable bowel syndrome, Interstitial cystitis

Bunions, chronic fatigue syndrome

Impacted tooth, tension headaches

Bunions, temporomandibular disorder

Which group of symptoms are most likely to be associated with fibromyalgia?

Migraine, tension headache, earache

Digestive symptoms, morning stiffness, blindness

Impaired cognition, nonrestorative sleep, fatigue

Catastrophizing, anxiety, foot infections

Which broad drug classes are located within the American Pain Society and European League Against Rheumatism treatment guidelines?

SNRIs, SSRIs

TCAs, RAAS

RAAS, AEDs

SNRIs, ACEI

Which medical term below, related to pain, is defined correctly?

Allodynia: Abnormally increased pain in response to a noxious stimulus (e.g., exaggerated pain response to a fingerstick)

Hyperalgesia: Abnormally increased pain in response to a noxious stimulus (e.g., exaggerated pain response to a fingerstick)

Somatic pain: impaired cognition, such as difficulty thinking, memory loss, and decreased mental alertness

Fibro-fog: Pain from within a body cavity (e.g., abdominopelvic, thoracic) that is more difficult to localize and tends to be described as colicky or squeezing

Which medications are approved by the Food and Drug Administration (FDA) for treating fibromyalgia?

Duloxetine, Pregabalin

Milnacipran, Amitriptyline

Duloxetine, Opioids

Pregabalin, Fluoxetine

Which drug-dose combination is most accurate for patients with fibromyalgia?

Duloxetine 300 mg to 600 mg twice daily

Milnacipran 1.25 mg to 20 mg three times daily

Pregabalin 75 mg twice daily to 450 mg/day

Pregabalin 150 mg/day to 4.5 gm daily

Which nonpharmacologic activities are suggested for patients with fibromyalgia?

Running marathons and swimming

Boxing and yoga

Triathlons and water exercises

Biking, walking, and dancing

A new, hypothetical Fibromyalgia Clinic Day (FCD) is created, where one day a month, patients with fibromyalgia have appointments with multiple providers on that day. Which group of professionals is LEAST likely to be incorporated into that FCD?

Exercise physiotherapist, physical therapist, mental health professional

Mental health professional, sleep specialist, dietician

Dietician, dentist, manicurist

Dietician, pain specialist, mental health professional

References

Hayes SM, Myhal GC, Thornton JF, et al. Fibromyalgia and the therapeutic relationship: where uncertainty meets attitude. Pain Res Manag. 2010;15(6):385-391. doi:10.1155/2010/354868

Perrot S, Choy E, Petersel D, Ginovker A, Kramer E. Survey of physician experiences and perceptions about the diagnosis and treatment of fibromyalgia. BMC Health Serv Res. 2012;12:356. Published 2012 Oct

10. doi:10.1186/1472-6963-12-356

Byrne A, Jones K, Backhouse M, Rose F, Moatt E, van der Feltz-Cornelis

C. Patient and primary care practitioners' perspectives on consultations for fibromyalgia: a qualitative evidence synthesis. Prim Health Care Res Dev. 2023;24:e58. Published 2023 Sep 26. doi:10.1017/S1463423623000506

Arnold LM, Choy E, Clauw DJ, et al. Fibromyalgia and Chronic Pain Syndromes: A White Paper Detailing Current Challenges in the Field. Clin J Pain. 2016;32(9):737-46. doi: 10.1097/AJP.0000000000000354

Berwick R, Barker C, Goebel A; guideline development group. The diagnosis of fibromyalgia syndrome. Clin Med (Lond). 2022;22(6):570-

574. doi:10.7861/clinmed.2022-0402

Galvez-Sánchez CM, Reyes Del Paso GA. Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives. J Clin Med. 2020;9(4):1219. Published 2020 Apr 23. doi:10.3390/jcm9041219

Galvez-Sánchez CM, de la Coba P, Colmenero JM, Reyes Del Paso GA, Duschek S. Attentional function in fibromyalgia and rheumatoid arthritis. PLoS One. 2021;16(1):e0246128. Published 2021 Jan 27. doi:10.1371/journal.pone.0246128

Teodoro T, Edwards MJ, Isaacs JD. A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review. J Neurol Neurosurg Psychiatry. 2018;89(12):1308-1319. doi:10.1136/jnnp-2017-317823

Siracusa R, Paola RD, Cuzzocrea S, Impellizzeri D. Fibromyalgia: Pathogenesis, Mechanisms, Diagnosis and Treatment Options Update. Int J Mol Sci. 2021;22(8):3891. Published 2021 Apr 9. doi:10.3390/ijms22083891

Sarzi-Puttini P, Giorgi V, Marotto D, Atzeni F. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol. 2020;16(11):645-660. doi:10.1038/s41584-020-00506-w

Harper DE, Ichesco E, Schrepf A, et. al. Resting Functional Connectivity of the Periaqueductal Gray Is Associated With Normal Inhibition and Pathological Facilitation in Conditioned Pain Modulation. J Pain. 2018;19(6):635.e1-635.e15. doi: 10.1016/j.jpain.2018.01.001

Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiology to therapy. Nat Rev Rheumatol. 2011;7(9):518-27. doi: 10.1038/nrrheum.2011.98

Russell IJ, Orr MD, Littman B, et.al. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum. 1994;37(11):1593-601. doi: 10.1002/art.1780371106

Lunn MP, Hughes RA, Wiffen PJ. Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. Cochrane Database Syst Rev. 2014;2014(1):CD007115. doi: 10.1002/14651858.CD007115.pub3

Henley P, Martins T, Zamani R. Assessing Ethnic Minority Representation in Fibromyalgia Clinical Trials: A Systematic Review of Recruitment Demographics. Int J Environ Res Public Health. 2023;20(24):7185. Published 2023 Dec 15.

doi:10.3390/ijerph20247185

Wolfe F, Walitt B, Perrot S, Rasker JJ, Häuser W. Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias. PLoS One. 2018;13(9):e0203755. Published 2018 Sep 13.

doi:10.1371/journal.pone.0203755

Jones GT, Atzeni F, Beasley M, Flüß E, Sarzi-Puttini P, Macfarlane GJ. The prevalence of fibromyalgia in the general population: a comparison of the American College of Rheumatology 1990, 2010, and modified 2010 classification criteria. Arthritis Rheumatol. 2015;67(2):568-575. doi:10.1002/art.38905

Salaffi F, Di Carlo M, Bazzichi L, et. al., Definition of fibromyalgia severity: findings from a cross-sectional survey of 2339 Italian patients. Rheumatology (Oxford). 2021 Feb 1;60(2):728-736. doi: 10.1093/rheumatology/keaa355

Galvez-Sánchez CM, Duschek S, Reyes Del Paso GA. Psychological impact of fibromyalgia: current perspectives. Psychol Res Behav Manag. 2019;12:117-127. Published 2019 Feb 13. doi:10.2147/PRBM.S178240

Yunus MB. The prevalence of fibromyalgia in other chronic pain conditions. Pain Res Treat. 2012;2012:584573. doi:10.1155/2012/584573

Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319-329. doi:10.1016/j.semarthrit.2016.08.012

Kang JH, Choi SE, Park DJ, Lee SS. Disentangling Diagnosis and Management of Fibromyalgia. J Rheum Dis. 2022;29(1):4-13. doi:10.4078/jrd.2022.29.1.4

Häuser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome - a systematic review. Eur J Pain. 2010;14(1):5-

10. doi: 10.1016/j.ejpain.2009.01.006

Häuser W, Petzke F, Üçeyler N, Sommer C. Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran in fibromyalgia

syndrome: a systematic review with meta-analysis. Rheumatology (Oxford). 2011;50(3):532-43. doi: 10.1093/rheumatology/keq354

Cymbalta. Prescribing Information. Eli Lilly and Co. April 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021427s0 52lbl.pdf. Accessed October 6, 2024

Savella. Prescribing Information. Forest Laboratories, Inc. December 2012.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022256s0 13lbl.pdf. Accessed October 6, 2024.

Lyrica. Prescribing Information. Pfizer, Inc. June 2020. https://labeling.pfizer.com/ShowLabeling.aspx?format=PDF&id=561. Accessed October 14, 2024.

Borchers AT, Gershwin ME. Fibromyalgia: A Critical and Comprehensive Review. Clin Rev Allergy Immunol. 2015;49(2):100-51. doi: 10.1007/s12016-015-8509-4

Amitriptylline hydrochloride. Prescribing Information. Sandoz. May 2014.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/085966s0 95,085969s084,085968s096,085971s075,085967s076,085970s072lbl.p

df. Accessed October 14, 2024.

Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for fibromyalgia in adults. Cochrane Database Syst Rev. 2019;5(7):CD011824. doi: 10.1002/14651858.CD011824

Amrix. Prescribing Information. Teva Pharmaceuticals USA, Inc. April 2019.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021777s0 17lbl.pdf. Accessed October 14, 2024.

Moldofsky H, Harris H, Archambault W, Kwong T, Lederman S. Effects of bedtime very low dose cyclobenzaprine on symptoms and sleep physiology in patients with fibromyalgia syndrome: a double-blind randomized placebo-controlled study. J Rheum. 2011;12:2653-2663. doi:10.3899/jrheum.110194

Prozac. Prescribing Information. Eli Lilly and Co. January 2017. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018936s1 08lbl.pdf. Accessed October 14, 2024.

Arnold LM, Hess EV, Hudson JI, Welge JA, Berno SE, Keck PE Jr. A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Am J Med. 2002;112(3):191-7. doi: 10.1016/s0002-9343(01)01089-0

Moret C, Briley M. Antidepressants in the treatment of fibromyalgia. Neuropsychiatr Dis Treat. 2006 Dec;2(4):537-48. doi: 10.2147/nedt.2006.2.4.537

Gabapentin. Prescribing Information. Pfizer, Inc. April 2009. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020235s0 41,020882s028,021129s027lbl.pdf. Accessed October 14, 2024.

Cooper TE, Derry S, Wiffen PJ, Moore RA. Gabapentin for fibromyalgia pain in adults. Cochrane Database Syst Rev. 2017;1(1):CD012188. doi: 10.1002/14651858.CD012188.pub2

Sayar K, Aksu G, Ak I, Tosun M. Venlafaxine treatment of fibromyalgia. Ann Pharmacother. 2003;37(11):1561-5. doi: 10.1345/aph.1D112

Venlafaxine. Prescribing Information. Trigen Laboratories. October 2017.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022104s0 16lbl.pdf. Accessed October 14, 2024.

Sayar K, Aksu G, Ak I, Tosun M. Venlafaxine treatment of fibromyalgia.

Ann Pharmacother. 2003;37(11):1561-5. doi: 10.1345/aph.1D112

Alorfi NM. Pharmacological Methods of Pain Management: Narrative Review of Medication Used. Int J Gen Med. 2023;16:3247-3256. doi: 10.2147/IJGM.S419239

Mascarenhas RO, Souza MB, Oliveira MX, et al. Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA Intern Med. 2021;181(1):104-112. doi:10.1001/jamainternmed.2020.5651

Busch AJ, Webber SC, Richards RS, et. al.. Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev. 2013;2013(12):CD010884. doi: 10.1002/14651858.CD010884

Flynn DM. Chronic Musculoskeletal Pain: Nonpharmacologic, Noninvasive Treatments. Am Fam Physician. 2020;102(8):465-477

Qureshi AG, Jha SK, Iskander J, et. al. Diagnostic Challenges and Management of Fibromyalgia. Cureus. 2021;13(10):e18692. doi: 10.7759/cureus.18692

Cheema R, Chang-Miller A, Aslam F. Myalgia with Elevated Inflammatory Markers in an Obese Young Female: Fibromyalgia or Polymyalgia Rheumatica? Am J Case Rep. 2019;20:659-663. doi: 10.12659/AJCR.915564

NIH. National Library of Medicine. Evaluation of chronotype and central sensitization in patients with fibromyalgia syndrome. Clinicaltrials.gov. January 17, 2024. https://clinicaltrials.gov/search?cond=Fibromyalgia&aggFilters=status:n ot rec. Accessed October 14, 2024.

NIH. National Library of Medicine. Metformin for fibromyalgia symptoms (INFORM Trial). Clinicaltrials.gov. October 10, 2023. https://clinicaltrials.gov/study/NCT05900466?cond=Fibromyalgia&aggFi lters=status:not rec&rank=5tatus:not rec&rank=1. Accessed October 14, 2024.

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Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

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