Your patient presents with widespread pain, joint stiffness, fatigue, and mood disturbances. Your next step?
References1. Higgs JB. Fibromyalgia in primary care. Prim Care Clin Office Pract. 2018;45:325-341.2. CDC. Fibromyalgia. https://www.cdc.gov/arthritis/basics/fibromyalgia.htm. Accessed June 19, 2018.3. Hadker N, Suchita G, Chandran AB, et al. Primary care physicians’ perceptions of the challenges and barriers in the timely diagnosis, treatment and management of fibromyalgia. Pain Res Manag. 2011;16:440-444.4. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62:600-610.5. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46:319-329.6. Kodner C. Common questions about the diagnosis and management of fibromyalgia. Am Fam Physician. 2015;91:472-478.7. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76:318-328.
Fibromyalgia is a controversial condition. There is no clear cause, no definitive diagnostic tests, and only a modest response to therapy. Patients often have difficulty convincing others that their symptoms are real.
To help you deal with the challenges of caring for patients with fibromyalgia, I offer a straightforward approach. Scroll through the slides for the details.
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One in 20 patients in primary care may have fibromyalgia,1 and women have twice the risk of men.2 The average delay in diagnosis is 2 years. About 46% of primary care physicians report uncertainty with the diagnosis of fibromyalgia.3
Symptoms include widespread pain, joint stiffness, nonrestorative sleep, fatigue, mood disturbances, altered cognition (“fibrofog”), and headaches. Fatigue has been reported as the worst symptom.
Fibromyalgia has many comorbid conditions, including temporomandibular joint and muscle (TMJ) disorders, irritable bowel syndrome (IBS), interstitial cystitis, anxiety/depression, vulvodynia, chronic back pain, endometriosis, noncardiac chest pain, posttraumatic stress disorder (PTSD), and restless legs syndrome.
In 2010, the American College of Rheumatology (ACR) released preliminary diagnostic criteria for fibromyalgia.4 Note that the tender point examination is no longer required but may be useful.
The ACR has not yet endorsed the 2016 revised criteria.5
Other diagnostic considerations include the results of a tender point examination: pain at 11 of 18 sites (left and right side, above and below waist). The examination has a sensitivity of 88% and a specificity of 81%.
No standard laboratory tests are required. The minimum tests recommended are creatinine, calcium, aspartate aminotransferase (AST), alanine aminotransferase (ALT), thyroid-stimulating hormone (TSH), complete blood cell (CBC) count, urinalysis, and basic metabolic panel (BMP). The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), antinuclear antibody (ANA), and other serologic tests are poor screening tools.
The American Academy of Family Physicians (AAFP) recommends evaluation for comorbid functional pain syndromes, sleep disorders, and mood disorders.6
Management follows an organized team approach in the primary care medical home model. The most recent management guidelines were released by the European League Against Rheumatism (EULAR) in 2016.7
The cornerstone of care consists of education, cognitive behavioral therapy (CBT), sleep hygiene, regular aerobic exercise, and management of comorbidities. The most consistent evidence is for the efficacy of exercise. No consistent evidence supports the efficacy of any complementary and alternative medicine (CAM) modality.
Pharmacotherapy for fibromyalgia has variable efficacy. Three medications have been approved by the FDA for fibromyalgia: duloxetine, milnacipran, and pregabalin. Tricyclic antidepressants (TCAs) such as amitriptyline, serotonin-norepinephrine reuptake inhibitors (SNRIs), and cyclobenzaprine have the strongest evidence for benefit. Others with some efficacy are gabapentin and tramadol; however, the use of tramadol to treat fibromyalgia is controversial. Nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), opioids, antiepileptics, and corticosteroids are generally ineffective for fibromyalgia.
Note that patients discontinue more than 50% of prescriptions because of inefficacy or adverse effects.1
Among the most common indications for referral are concern for systemic rheumatic disease, suspected psychiatric condition other than anxiety/depression, suicidal ideation, narcotic-dependent pain, suspected statin myalgia in known cardiovascular disease (CVD), administrative disability claim, inability to do limited exercise, and concern for chronic infection.