Fibromyalgia

John Buckner Winfield, M.D.
University of North Carolina School of Medicine

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
  • Multiple defined tender points
    • Second rib anteriorly
    • Occiput
    • Low cervical
    • Trapezius midpoint
    • Supraspinatus
    • Lateral epicondyle
    • Gluteal
    • Greater trochanter
    • Knee medial fat pad
  • Fatigue
  • Disturbed/nonrestorative sleep
• 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)

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Differential Diagnosis

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

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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

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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

• Tricyclic antidepressants (TCAs)
  • Amitriptyline
    • Dose: 10 mg q.h.s. starting dose, escalating slowly to 50 mg q.h.s.
    • Cost/mo: $9
• Cyclobenzaprine
  • Dose: 10 mg q.h.s.
  • Cost/mo: $49
• Selective serotonin reuptake inhibitors (SSRIs)
  • Fluoxetine
    • Dose: 20–40 mg daily
    • Cost/mo: $16
  • Citalopram
    • Dose: 20–40 mg daily
    • Cost/mo: $40
• Serotonin/noradrenaline reuptake inhibitors (SNRIs)
  • Duloxetine
    • Dose: 20–60 mg daily
    • Cost/mo: $100
  • Venlafaxine
    • Dose: 150–225 mg daily divided b.i.d.–t.i.d.
    • Cost/mo: $95
• Combination therapy of TCA with SSRI or duloxetine
• 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
    • Cost/mo: $30
  • Topiramate
    • Dose: 25–50 mg q.h.s. to 200 mg b.i.d.; escalate by 25–50 mg at weekly intervals
    • Cost/mo: $162
  • Tiagabine
    • Dose: 2–4 mg q.h.s. to 56 mg q.d. in two to four divided doses; escalate by 4–8 mg at weekly intervals
    • Cost/mo: $314
• Adjunctive drug therapy
  • Anxiolytics
    • Benzodiazepines (clonazepam, temazepam)
    • Buspirone

• Modafinil
  • Dose: 100–200 mg q.a.m.
  • Cost/mo: $186
• SSRIs
• Methylphenidate
  • Dose: 20–30 mg daily

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

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Best References

Bennett RM: Rheum Dis Clin North Am 28:181, 2002 [PMID 12122913]

Goldenberg DL, et al: JAMA 292:2388, 2004 [PMID 15547167]

Wolfe F, et al: Arthritis Rheum 33:160, 1990 [PMID 2306288]