9/20/17. Fibromyalgia: Pearls and Pitfalls. Disclosure. Objectives

Transcription

1 Fibromyalgia: Pearls and Pitfalls Lyne%e Cederquist, M.D. Clinical Professor of Medicine University of California, San Diego Nothing to disclose. Disclosure Objectives Iden6fy challenges of diagnosing fibromyalgia Discuss prac6cal approaches to the work up Outline a strategy for managing fibromyalgia 1

2 9/20/17 Diagnosing Fibromyalgia From: Fibromyalgia: A Clinical Review JAMA. 2014;311(15): doi: /jama Figure Legend: Example of a Patient Self-report Survey for the Assessment of Fibromyalgia Based on Criteria in the 2011 Modification of the ACR Preliminary Diagnostic Criteria for FibromyalgiaACR indicates American College of Rheumatology. Scoring information is shown in blue. The possible score ranges from 0 to 31 points; a score 13 points is consistent with a diagnosis of fibromyalgia. Additional scoring information and a printer-ready version of this survey that patients can complete are available online (efigure 1 and efigure 2 in the Supplement). Date of download: 4/11/2016 Copyright 2016 American Medical Association. All rights reserved. The Work Up Must take a detailed history: This takes anywhere from minutes! No short cuts! Physical exam examine joints, test for tender points Selec6ve labs don t need to rou6nely run rheumatologic tes6ng (ANA, RF) unless other findings suggest an underlying rheumatologic disorder TSH CPK/aldolase ESR Vitamin D Consider more extended work up for small fiber neuropathy if indicated 2

3 Do you have a disorder that would otherwise explain the pain? Chronic fa6gue syndrome Chronic widespread musculoskeletal pain spine disease arthri6s/hypermobility Hypothyroidism Depression Soma6za6on Disorder Polymyalgia rheuma6ca Small fiber neuropathy Sta6n induced myopathy Vitamin D deficiency Metabolic myopathy Chemical sensi6vity syndrome 20-50% of fibromyalgia cases have comorbidities. including: Chronic fa6gue syndrome/systemic exer6on intolerance syndrome (SEID) IBS Migraine/chronic headaches TMJ/TMD (temporomandibular disorder) Chronic bladder/pelvic pain syndromes IC, vulvodynia Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical condidons. Ann Intern Med. 2001;134(9 Pt 2):868. Co-existing Disorders 25% have major depression 50% have life6me history of depression Sleep disorders: insomnia, RLS, periodic limb movement disorders, sleep apnea Arnold LM, et. Al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry. 2006;67(8):

4 Diagnostic Pearls Keep an open mind you don t have to diagnose the pa6ent on the first 1 or 2 visits Befer to iden6fy and treat specific sources of pain and fa6gue before labeling everything as fibromyalgia A diagnosis is helpful only when it helps guide management Management of Fibromyalgia Founda6on of care is Self Care and Pa6ent Educa6on! This should be a primarily pa6ent managed, not doctor managed condi6on Our role is more of an educator/mo6vator/coach This is also 6me consuming, but sets the founda6on of moving forward with more successful management and improved outcome Patient Education/Coaching Before discussing any medica6ons, focus on the pa6ent s: Current ac6vity level and exercise regimen Ac6vity pacing is key! - you can t live your life going 100 mph, but you also don t want to stay in park lying in bed. Try to structure your life to live going 50 mph Consistent low impact aerobic exercise is a must - coaching, nagging, coaching! 4

5 What impact does patient education have on outcomes? 2004 review: fibromyalgia pa6ents receiving educa6on had significantly more improvement in symptoms, improved quality of life, and increased ac6vity tolerance. Goldenberg DL, et. al. Management of fibromyalgia syndrome. JAMA. 2004;292(19):2388. Five Key Pain Coping Skills Understanding Accep6ng ACT, acceptance and commitment therapy, reduced catastrophizing Calming stress reduc6on, MBSR, biofeedback, breathing Balancing ac6vity pacing Coping what kind of pain am I having, and what can I do to relieve it? 2013 study in Pain and Therapy, Ted W. Jones, PhD, Behavioral Medicine Ins6tute at Pain Consultants of East Tennessee in Knoxsville measured outcomes of a single 2 hour group session using the Pain Catastrophizing Scale. Nutrition Less evidence behind nutri6onal aspects impac6ng fibromyalgia, but seems intui6vely important to address: Some reports of pa6ents improving on a gluten free diet small trial of FODMAP helping in pts with fms and ibs High Omega-3 diet Vitamin B mg, vitamin B mg, folic acid. 5-2 mg, and vitamin B12, Vitamin D 800-1,000 units/day Magnesium glycinate mg twice a day Carni6ne 2000 mg/day Ather Ali,ND,MPH, McCarthy, P. M.D., Complementary and Integra6ve Methods in Fibromyalgia. Pediatr Rev Dec.; 35(12):

6 Nutrition (cont.) D-ribose 5 grams twice daily Rhodeola 200 mg daily Coenzyme Q mg/day SAMe 800 mg/day Must do an 8-12 week trial of any supplement to determine its effect Mind Body Practices Mindfulness Based Stress Reduc6on maybe a slide on each of these therapies and evidence and pointers on using in fibro ie how many tx what type etc Tai Chi Yoga CBT? Acupuncture Guided imagery Virtual Reality therapy (?) future possibility Self-help Resources Online Tai Chi: hfps://youtu.be/hiohgrycej4 Tai chi siqng: hfps:// Gentle chair yoga: hfps:// Guided medita6on for pain relief: hfps:// Mindfulness for pain relief: hfps:// 6

7 Medication Regimen Medica6ons should be discussed last! If you are not prac6cing good self care, I can throw all the pills at you I want, and you will not feel befer Op6ons: pregabalin, duloxe6ne, milnacipran, gabapen6n, venlaflaxine, TCA s, cyclobenzaprine, tramadol Maybe a table on these I know there are a few out there ie from PPM and others Off label: compounded low dose oral naltrexone 4.5 mg qhs there will likely be ques6ons on this Strategies to Monitor Response to Therapy Track Patient Self-report Survey for the Assessment of Fibromyalgia Score Track Fibromyalgia Impact Ques6onnaire Fibromyalgia is a Chronic Incurable Condition Needs ongoing follow up! Review how pa6ent is doing with lifestyle/self care Adjust medica6on regimen Ongoing coaching and educa6on 7

8 The Invisible Disease 8