Posted by MERM on 6/6/2008, 9:38 am, in reply to "DX and TREATMENT OF FM HAS CHANGED LITTLE OVER THE YEARS "
The diagnosis may be confused with other conditions, including myofascial syndrome, rheumatoid arthritis or osteoarthritis, among other conditions. An accurate diagnosis is critical because the treatments are very different.
Conditions similar to fibromyalgia
A few similar conditions include:
Fibromyalgia is perhaps most commonly confused with myofascial pain syndrome. Myofascial pain syndrome is regional pain syndrome, characterized by palpable, "trigger points" that produce pain in a referred distribution (another part of the body) (21).
Rheumatoid arthritis and osteoarthritis resemble fibromyalgia early in the course of the disease. In one study concurrent fibromyalgia was identified in 13% and 10% of patients with rheumatoid arthritis and osteoarthritis, respectively. In general, these individuals had a higher level of severity of pain and disability
Management of Fibromyalgia
Comprehensive approach to managing fibromyalgia
The precise pathophysiologic basis of fibromyalgia has yet to be clearly and convincingly illustrated. Fibromyalgia is known to be a chronic disorder, which means that there is no "cure" for fibromyalgia. Instead, treatment involves a coordinated management program to alleviate the symptoms.
The goals of a management program should include the following components:
Correct diagnosis of fibromyalgia
Patient education about fibromyalgia
Sleep enhancement for fibromyalgia
Aerobic fitness for fibromyalgia
In addition to the above, effective treatments for fibromyalgia may also include various medications (such as muscle relaxants). Most of these medications have typically been studied in clinical trials and information is available about their efficacy in alleviating the symptoms of fibromyalgia.
Other non-medicinal therapies are also sometimes used to manage the symptoms of fibromyalgia. While few clinical trials have been conducted to evaluate the efficacy of these therapies, there are some anecdotal reports of improvements for some patients’ symptoms.
Medications for fibromyalgia
Various classes of medications have been evaluated in the treatment of fibromyalgia, including:
Tricyclic anti-depressants
Muscle relaxants
Sedatives/hypnotics
Non-steroidal anti-inflammatory medications (NSAID’s)
Cortico steroids
Tricyclic anti-depressants
Tricyclic anti-depressants that are commonly used in the treatment of fibromyalgia include Amitriptyline (Elavil), Nortriptyline (Pamelor), and Doxepin (Sinequan). Amitriptyline is perhaps the most common as its efficacy has been demonstrated in controlled studies and it is known to enhance stage 3 and 4 sleep.
In a study of 70 fibromyalgia patients that evaluated the efficacy of 50 mg of Amitriptyline, patients receiving the Amitriptyline had significantly improved quality of sleep, morning stiffness, pain analog and global assessment. Interestingly, tender point score did not improve. 40
Common side effects of Amitriptyline may include morning sedation, dry mouth, confusion and urinary retention. Fibromyalgia patients seem especially sensitive to these side effects. Therefore, the dose should be individualized and generally begun at the lowest possible dose (such as 5 to 10 mg) at nighttime. Taking the drug 1 to 2 hours prior to sleep can minimize difficulties with morning sedation or "hangover". If there is no response, the dose can increase after 2 to 3 weeks.
Muscle relaxants
Muscle relaxants such as Cyclobenzaprine (Flexeril) and Orphenadrine Citrate (Norflex) have also been studied in the treatment of fibromyalgia. Cyclobenzaprine has a tricyclic chemical structure similar to Amitriptyline, yet its anti-depressant effects are minimal. It is used only as a short-term muscle relaxant
In a study of 120 fibromyalgia patients, those receiving Cyclobenzaprine (10 to 40 mg) over a 12 week period had significantly improved quality of sleep and pain score. There was a trend towards improvement in fatigue symptoms but not in duration of morning stiffness. Interestingly, there was also a reduction in the total number of tender points and muscle tightness. 41
For use in treating fibromyalgia, common beginning dosages are generally 5 to 10 mg at bedtime. Again, common side effects include dry mouth, drowsiness, and constipation.
Orphenadrine Citrate (Norflex) is a centrally acting analgesic muscle relaxant. It is used as an adjunct to rest, physical therapy and symptomatic measures for acute musculoskeletal pain.
In an abstract that reviewed the response of Orphenadrine Citrate in 85 fibromyalgia patients, over a one-year period a significant, sustained improvement in general pain was noted in 34% of patients taking Orphenadrine Citrate (vs. 15% and 10% of patients taking Amitriptyline and Cyclobenzaprine, respectively).
The usual short-term dosage is one tablet (100 mg). Common side effects include confusion, anxiety and tremors, dry mouth and tachycardia. A few contra-indications include glaucoma, prostatic hypertrophy, pyloric/duodenal obstruction or stenosing peptic ulcers. With prolonged use, periodic monitoring of blood, urine and liver function tests are recommended.
Sedative/hypnotics
Sedative/hypnotics may also have a role in the comprehensive management of fibromyalgia. Because fibromyalgia patients typically report that their sleep is not refreshing, some physicians may recommend the use of sedatives/hypnotic medications to enhance sleep.
Temazepan (Restoril), Flurazepan (Dalmane) and Triazolam (Halcion) are Benzodiazepine agents commonly used for short-term management of insomnia. Controlled, double blind studies of their efficacy and safety for fibromyalgia patients have not yet been conducted. Anecdotally, one physician found "total resolution of symptoms within 1 to 4 weeks" in 10 of 14 fibromyalgia patients (5). Dosages, administration and method of evaluation and side effects were not reported.
Common side effects of these sedative/hypnotic drugs include excessive drowsiness, confusion, nausea, tachycardia, nightmares and even (paradoxically) insomnia. Contra-indications include pregnancy and glaucoma. These drugs are not recommended for long-term use, and withdrawal symptoms have been reported.
Non-steroidal anti-inflammatory drugs (NSAID’s)
NSAID’s have commonly been used to treat fibromyalgia. Fibromyalgia patients most commonly report generalized pain and stiffness. NSAID’s are commonly used for their anti-inflammatory and analgesic (pain-killing) properties 43,44.
Unfortunately, despite their widespread use, NSAID’s have not been shown to be very effective in relieving the painful symptoms of fibromyalgia. There is no documented evidence of inflammatory changes associated with this syndrome.
In a study of 46 fibromyalgia patients that compared Ibuprofen to placebo, both groups reported interval improvement in fatigue, pain, tender points, and subjective swelling and there was no significant difference between the two groups 44.
In another 6 week study of 62 fibromyalgia patients, groups of patients were given the tricyclic anti-depressant Amitriptyline, the NSAID Naproxen, both drugs or neither drug. Although there was initial improvement in pain at two weeks in the Naproxen group, the difference was not significant.
While these studies do not demonstrate the efficacy of NSAID’s for fibromyalgia patients, they may have clear benefits for fibromyalgia patients with concomitant and exacerbating conditions such as osteoarthritis, rheumatoid arthritis, or other conditions.
Cortico steroids
Steroids have been assessed for treatment of fibromyalgia. In a two-week study to assess the efficacy of Prednisone, there was no significant difference between the Prednisone or placebo or baseline 46. However, it is thought that a therapeutic trial of Prednisone may be beneficial for the patient if a co-existent, steroid responsive disorder is suspected.
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