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Nonpharmacologic tactics key for fibromyalgia: core elements are education, exercise, sleep hygiene, psychological support, and stress management.

EXPERT ANALYSIS FROM A CONFERENCE ON INTERNAL MEDICINE SPONSORED BY THE UNIVERSITY OF COLORADO

ESTES PARK, COLO. -- Nonpharmacologic therapy is as important as medications in the successful management of fibromyalgia, yet the nondrug interventions are greatly underutilized, Dr. Sterling G. West asserted at the meeting.

"Nonpharmacologic therapy has to be used. If you don't, you won't get near the success rate you will by combining it with pharmacotherapy," said Dr. West, professor of medicine and a rheumatologist at the University of Colorado, Aurora.

The core elements of nonpharmacologic therapy for this challenging disorder are education, exercise, sleep hygiene, psychological support, and stress management.

Two educational websites that he recommends for his fibromyalgia patients are www.fmaware.org and www. knowfibro.com.

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"You'll find they get 20% better just knowing what they're dealing with," according to Dr. West.

He particularly likes www.knowfibro.com. "It basically tells patients that it's up to them to get better. They can't just lay back and say, 'Give me disability.' They have to participate and actively try to improve," the rheumatologist explained.

The emphasis with regard to exercise needs to be on aerobic activity. Patients must understand the importance of exercising on their bad days as well as good days and that their pain may initially get worse as they become more active.

Fibromyalgia patients are exquisitely sensitive to medications and their side effects. The same is true for exercise. As with drug prescriptions, the exercise prescription has to start low and build up gradually. A good rule of thumb is to begin with 15 minutes of physical activity per day, increasing it by 5 minutes per day each week until reaching 30 minutes per day.

The intensity is gradually boosted to the moderate range, or 75% of maximum heart rate. For patients who find land-based exercise too painful at first, warm water exercise is a good alternative. The Arthritis Foundation sponsors pool-based warm water exercise programs in every state that are available to fibromyalgia patients.

Sleep apnea is quite common in patients with fibromyalgia, many of whom aren't particularly overweight. It needs to be addressed as part of the comprehensive treatment of this pain disorder, Dr. West continued.

The need to involve a skilled psychologist often becomes apparent at a physician's initial encounter with a fibromyalgia patient. Two questions Dr. West always asks as part of his history taking are, "What do you do to cope with your pain?" and "Do you think your pain will ever get better?"

"If a patient answers no to that second question, you know you're in big trouble because the patient is catastrophizing. That means you need to elicit the help of a psychologist with expertise in pain to help you deal with this. Your patient is going to need their help in addition to the things you're going to do," he explained.

Another situation in which a psychologist's help is essential is in the fibromyalgia patient with early-life trauma in the form of sexual and/or physical abuse. Often patients with the most severe fibromyalgia have such a history.

"The patient may have never previously been asked about early-life trauma. If you're going to unroof that scab, you'd better have someone in the background who can help you," Dr. West advised.

Strong evidence supports the utility of cognitive-behavioral therapy in improving pain, fatigue, physical function, and mood.

An estimated 6 million American adults have fibromyalgia, making this disorder more common than gout.

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The current view of fibromyalgia is that it's an afferent processing disorder leading to central and peripheral amplification of pain pathways and additional somatic complaints.

It features increased excitation at the level of the dorsal horn nuclei and inhibition of descending pathways responsible for diffuse noxious inhibitory control. Insight into the neurotransmitters involved has led to more rational use of medications.

Nonetheless, the clinical trial data for drug therapy point to effect sizes that are "modest at best" for all drug classes, he observed.

About "30%-40% of patients get 40%-50% relief of their pain; that's what you can tell patients they can expect. But those are averages. You'll have patients who respond well to their medicine and others who won't respond at all. You can't tell which ones are going to respond well and which aren't until you try them. You try a drug, and, if it doesn't work, you try something different, and you keep on until you find what works best," Dr. West said.

The strongest evidence of efficacy exists for the Food and Drug Administration--approved drugs duloxetine, milnacipran, and pregabalin, along with the off-label agents venlafaxine, gabapentin, cyclobenzaprine, and the tricyclic antidepressants. All of those off-label drugs are supported by a body of literature supporting effectiveness, and they make for good alternatives when patients cannot afford the approved drugs, which are invariably more expensive, he said.

The numbers-needed-to-treat to achieve a 30% reduction in pain have been calculated at 7.2 for duloxetine, 8.6 for pregabalin, and 19 for milnacipran.

"All of these patients with fibromyalgia come to us with pain," Dr. West noted. "I choose their medications based on what their chief complaint is."

For example, a fibromyalgia patient who presents with pain, prominent fatigue, and depressed mood is a good candidate for duloxetine (Cymbalta), which fortuitously is also approved for osteoarthritis pain.

A patient who complains of pain, cognitive dysfunction or "fibrofog," and fatigue may do well with milnacipran (Savella) starting at 12.5 mg in the morning with food, titrated upward by 12.5 mg per week to a maximum of 50 mg b.i.d. Pain with sleep disturbance is a symptom cluster that often responds well to pregabalin (Lyrica), dosed at 50 mg with food before bed, increased by 25 mg/day weekly to at least 150 mg/day before a morning dose is added, with a ceiling of 225 mg b.i.d..

Tramadol is supported by "modest" evidence of efficacy as an add-on niche medication for patients with substantial pain despite their baseline medications, the rheumatologist continued. Its efficacy in fibromyalgia is not through its better-known mu-opioid receptor agonist effect, but rather through the mechanism of serotonin-norepinephrine reuptake inhibition. Dr. West said that he starts tramadol at 25 mg/day and increases it weekly to a maximum of 100 mg four times daily.

Rational combination therapies utilizing different mechanisms of action and that are backed by supporting efficacy data include milnacipran plus pregabalin, venlafaxine and gabapentin, and fluoxetine and either amitriptyline or cyclobenzaprine, the rheumatologist continued.

Nearly all the medications recommended for treatment of fibromyalgia other than pregabalin and gabapentin modulate serotonin. That means patients need to be monitored for the development of suicidal ideation as well as serotonin syndrome. A simple way to check for emergent serotonin syndrome is to regularly evaluate the patient's deep tendon reflexes.

"If a patient suddenly becomes much more hyper-reflexive, you need to start dialing it down because you're putting them at risk for serotonin syndrome," Dr. West cautioned.

It's evident that many physicians are struggling with the use of medications to treat patients with fibromyalgia. "There's a gap between the evidence and what medications are actually prescribed in practice," Dr. West observed at the meeting.

This gap was highlighted by data from the REFLECTIONS study, presented at last year's annual scientific meeting of the American Pain Society. REFLECTIONS is an Eli Lilly--sponsored longitudinal study of 1,700 fibromyalgia patients and 91 physicians.

The physicians collectively prescribed 186 different medications to treat individuals who had fibromyalgia. Only about one-quarter of the physicians used one of the FDA-approved drugs. Opioids and nonsteroidal anti-inflammatory drugs were used just as frequently, even though these medications have zero evidence of efficacy in fibromyalgia and experts agree that they are of no help.

Dr. West reported having no financial conflicts.
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Title Annotation:MUSCULOSKELETAL DISORDERS
Author:Jancin, Bruce
Publication:Family Practice News
Geographic Code:1USA
Date:Sep 15, 2012
Words:1303
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