Fibromyalgia

John Buckner Winfield, MD
University of North Carolina School of Medicine, Chapel Hill, NC

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

• Chronic syndrome marked by the following:
  • Generalized pain
  • Increased sensitivity to pain (hyperalgesia, allodynia)
  • Fatigue
  • Disturbed/nonrestorative sleep
  • Cognitive dysfunction
• Female predominance
• May occur in children
• Frequently associated with self-assessed anxiety or depression; multiple other somatic complaints also common (e.g., headache, irritable bowel syndrome)
• Frequently coexists with organically defined disease (e.g., rheumatoid arthritis, SLE)

back to top

Differential Diagnosis

• Rheumatoid arthritis, Sjögren syndrome
• SLE
• Polymyalgia rheumatica
• Spondyloarthropathies
• Inflammatory myopathy (including statin myopathy)
• Hypothyroidism
• Hepatitis C
• Osteomalacia
• Cervical radiculopathy
• Multiple sclerosis

back to top

Best Tests

• Physical examination objectively normal in uncomplicated disease; abnormal physical or neurologic findings suggest comorbid disorder or alternative diagnosis
• No specific laboratory abnormalities
• Perform limited screening for comorbid disorders and for other disorders that cause pain and fatigue
• Antinuclear antibody
• CBC
• ESR or C-reactive protein
• TSH
• Creatine kinase
• AST, ALT
• Urinalysis

back to top

Best Therapy*

• Aerobic exercise
• Biofeedback and stress management
• Yoga
• Meditation
• Psychological intervention
• Support groups
• Guide patients to reliable sources of information
• Arthritis Foundation
• American College of Rheumatology
• Fibromyalgia Society
• Patient education
• Disorder is in perception of pain
• The pain as perceived is real
• Patient takes active role in managing symptoms

Drug Therapy

• Tricyclic antidepressants (TCAs)
• Amitriptyline
• Dose: 10 mg q.h.s. starting dose, escalating slowly to 50 mg q.h.s.
• Cyclobenzaprine
• Dose: 10 mg q.h.s.
• Selective serotonin reuptake inhibitors (SSRIs)
• Fluoxetine
• Dose: 20–40 mg daily
• Citalopram
• Dose: 20–40 mg daily
• Serotonin/noradrenaline reuptake inhibitors (SNRIs)
• Duloxetine
  • Dose: 20–60 mg daily
• Milnacipran
• Dose: 50–100 mg b.i.d.
• Combination therapy of TCA with SSRI or SNRI
• Antiepileptics (combined with antidepressants) for treatment of marked hyperalgesia and allodynia
• Gabapentin
• Dose: 300 mg q.h.s. to 600 mg t.i.d.; escalate over several weeks
• Pregabalin
• Dose: 30 mg daily to 60 mg daily; escalate over 1–2 weeks
• Adjunctive drug therapy
• Anxiolytics
• Benzodiazepines (clonazepam, temazepam)
• Buspirone

• Modafinil
• Dose: 100–200 mg q.a.m.
• SSRIs
• Methylphenidate
• Dose: 20–30 mg daily
• Armodafinil
• Dose: 50–250 mg q.a.m.

• SNRIs
• Venlafaxine
• Duloxetine
• Other
• SSRIs
• Fluoxetine
• Citalopram
• Multiple other

back to top

Best References

Yumus MB: Semin Arthritis Rheum 36:339-56, 2007 [PMID 17350675]

Moldofsky H: CNS Spectr 13(Suppl 5):22-6, 2008 [PMID 18323770]

Williams DA, Clauw DJ: J Pain 10:777-91, 2009 [PMID 19638325]

The author has been a member of the speakers' bureau of Wyeth, Pfizer, Lilly, Forest and a member of the advisory committee of Sanofi-Aventis, Inc.

* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=

August 2010