12 Dec 2014

Management of fibromyalgia

Fibromyalgia is a chronic pain syndrome. Patients have neuropsychiatric manifestation such as fatigue, depression, anxiety, sleep disturbances, apart from widespread pain. Basic abnormality is, altered pain processing in the brain

Laboratory investigations required in fibromyalgia are the following
1. Routine test.
2. Full blood count is done to  look for Anaemia and lymphopenia of SLE.
3. Erythrocyte sedimentation rate(ESR), C-reactive protein  elevated in Inflammatory disease.
4. Thyroid function to rule out Hypothyroidism.
5. Calcium, alkaline phosphatase  to search for Hyperparathyroidism, osteomalacia
Following investigations are done based on clinical history and physical examination
Antinuclear antibodies -SLE
Anti-SSA (anti-Sj√∂gren’s syndrome A) and anti-SSB
Rheumatoid factor and anticyclic citrullinated peptide (anti-CCP)
Creatine phosphokinase (CPK)
Viral and bacterial serologies
Spine and joint radiographs

In about 20% of cases associated rheumatologic disorders such a systemic lupus erythematosus, sjogrens syndrome, rheumatoid arthritis may be seen. Decreased serum calcium, low thyroid hormone, raised parathyroid hormone, infectious and inflammatory process all produce widespread musculoskeletal pain. Laboratory investigations will help to rule out the above mentioned conditions. Laboratory test are done after detailed clinical history and physical examination.

Treatment
The aims of treatment  are
1. To educate the patient about the disease,
2. Adequate  pain control
3. Improve sleep.
4. Improve the quality of life

As fibromyalgia adversely affect the quality of life treatment has to be planed according to individual patient. Both pharmacological and non pharmacological treatment are used to improve the outcome.
Behavioral therapy
Patients should be educated about the expectation for treatment. Excessive anxiety should be relieved. Illness behavior should be discouraged and behavior that improve the outcome should be encouraged. It is also aimed at maintaining normal sleep.
Exercise
One of the treatment strategy is physical conditioning. Aerobic exercise is started at low levels and consistently advanced. Relaxation with yoga or and Tai Chi may be helpful. Exercise programs are useful to reduce the pain and to improve the self eficasy.
Pharmacologic approaches
It is important to treat the triggers such as inflammation Steroids, and NSAIDS  may be useful for that. These are not effective in managing fibromyalgia symptoms.
Pharmacologic Agents Effective for treatment of Fibromyalgia
Antidepressants: (balanced serotonin:norepinephrine reuptake inhibition)
Amitryptiline
Duloxetine *
Milnacipran *
Anticonvulsants
Gabapentin
Pregabalina
*Approved for fibromyalgia by the U.S. Food and Drug Administration.

Utilisation of single drug to treat multiple symptom domain is strongly recommended
Example 1. If pain and sleep disturbances are the prominent symptoms. Agent that reduce pain and promote sleep is advised such as sedating antidepressants such as amitriptyline, gabapentin and pregabalin
Example 2. Pain with fatigue, anxiety, or depression. Agents that have both analgesic and antidepressant/anxiolytic effects, such as duloxetine or milnacipran, are  the best choice.

Drugs that should be avoided
Opioid analgesics should be avoided in fibromyalgia,because opoid induced hyperalgesia(increased pain )will worsen the symptoms.

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