9/20/17. Fibromyalgia Case Discussion. Objectives. Disclosure

Transcription

1 Fibromyalgia Case Discussion Lyne,e Cederquist M.D. Clinical Professor of Medicine University of California, San Diego Objectives IdenDfy challenges of diagnosing fibromyalgia Discuss pracdcal approaches to the work up Outline a strategy for managing fibromyalgia Nothing to disclose. Disclosure 1

2 61-year-old woman with gradual onset total body pain Started almost a year ago Achy, sdff muscle pain and achy joints. No joint swelling, no muscle weakness. She feels her pain is worse aqer exercising, but does not improve significantly with rest. Accompanied by worsening fadgue and poor sleep. She wakes up feeling exhausted. Her symptoms started during a period of extreme added stress at her job as a markedng representadve which required extensive travel PMH: Hypertension, hypercholesterolemia, Irritable bowel syndrome MedicaDons: lisinopril 10 mg daily, atorvastadn 40 mg daily, Metamucil daily, prn ibuprofen 61-year-old woman with gradual onset total body pain Social History: Married, was working full Dme as a markedng representadve for a soqware company. Quit working 3 months ago due to her worsening symptoms. Family History: NegaDve Review of Systems: General: No weight loss, fevers posidve for feeling more depressed past few months because of feeling poorly, not being able to work or exercising, and curbing her social acdvides because she doesn t feel well. Intermi,ent abdominal cramping with mostly consdpadon Her husband reports that she snores What else would you want to know? 2

3 What else would you want to know? Current level of acdvity and funcdon? She now spends 50% of the day resdng She has been off work for the past few months She has stopped exercising she used to go to the gym or go for a hike a few Dmes a week which she enjoyed Current diet, nutridon, substance use? She eats a fairly balanced diet Alcohol 2 glasses of wine 3-4x/week No smoking or drug use Does not take any vitamins or supplements Physical Exam: She does have 14 tender points on her exam bilateral cervical, anterior cricothyroid, supraclavicular, bilateral gluteal, greater trochanters, lateral epicondyles, and medial knees No joint swelling or warmth Muscle strength and tone are normal No rashes or skin lesions Neurologic exam is normal What would you include in your differential diagnosis? 3

4 Differential Diagnosis Fibromyalgia Vitamin D deficiency (?) Polymyalgia rheumadca StaDn induced myalgias Sleep apnea Depression Hypothyroid What labs or studies might you order? TSH ESR CPK Vitamin D Sleep study PHQ-9 Do you order RF, ANA? Work up 4

5 9/20/17 Patient Self Report Survey: Self report survey: Widespread Pain Index (WPI) score: 14/19 Symptom Severity score: 7 FaDgue: severe: 3 (severe) Trouble thinking or remembering: 2 (moderate) Unrefreshing sleep: 2 (moderate) Co-occuring condidons: Headaches: 1 Depression: 1 Total Score: 23 Patient Self-report Survey for the Assessment of Fibromyalgia Based on Criteria in the 2011 Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The possible score ranges from 0 to 31 points; a score 13 points is consistent with a diagnosis of fibromyalgia. 5

6 All of the studies come back normal. You conclude that she has fibromyalgia What might be a reasonable initial treatment plan? Fibromyalgia Initial Treatment Plan EducaDon! Counsel padent in detail regarding natural course of fibromyalgia Counsel padent about acdvity pacing Exercise plan Stress reducdon, mind body pracdces yoga, tai chi, MBSR Consider stadn holiday Provide list of potendally beneficial vitamins and supplements 2-month Follow up She is now pardcipadng in aquatherapy 3 x/week She has been taking Vitamin B complex, Vitamin D 1,000 IU/ day, magnesium glycinate 200 mg bid 6

7 She is feeling better overall, but still feels she needs more help with pain relief. Her fatigue is also better, but problematic. She is still hoping to return to work in the next few months. What treatments would you consider at this time? Starting a Medication Consider SNRI if padent has a significant concurrent mood disorder: DuloxeDne mg daily Milnacipran 50 mg bid If no mood disorder but poor sleep, consider a gabapendnoid: Pregabalin 150 mg bid GabapenDn mg Dd 7

8 Reasonable prn Medications Analgesic: tramadol Muscle relaxant: cyclobenzaprine Sleep agent: trazodone, melatonin Avoid: opiates, benzodiazepines, carisoprodol (Soma) For Fatigue, Consider Adding a mind body pracdce: Tai Chi, yoga, MBSR Trial of addidonal supplement: CarniDne 2,000 mg/day, D- ribose 5 gms bid, CoQ mg/day, or SAMEe 800 mg/ day She comes back for follow-up after 2 months on pregabalin 150 mg bid, as well as recommended supplements Pain is be,er FaDgue is a li,le be,er with supplements, and regular pracdce of Tai Chi Feels too groggy on the pregabalin Wants to try something else 8

9 What might you try next? Alternate Medications to Consider DuloxeDne Milnacipran TCA amitriptyline or nortriptyline Low dose naltrexone Patient now remembers she took duloxetine 3 years ago and had intolerable nausea, so she does not want to try it again. She also does not want to try milnacipran for the same reason. 9

10 Her recent ECG revealed a prolonged QTc so you don t want to use a TCA You decide to do a trial of low dose naltrexone, 4.5 mg qhs Next 2-month follow up, her fibromyalgia treatment plan now consists of: 3x/week aquatherapy 1x/week Tai Chi class AcDvity pacing adheres to a consistent moderate schedule Vitamin B complex, Vitamin D Magnesium glycinate, CoQ10 supplement Low dose naltrexone 4.5 mg qhs Patient still has pain and fatigue, but manageable. She has started looking for part time employment SUCCESS! (because everybody likes ahappy ending) 10

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