Fibromyalgia: The pain condition with many faces

Fibromyalgia, with its wide range of symptoms that can vary daily and over time, is one of the most challenging conditions I treat in my pain practice. This condition was originally not accepted by the medical community, because of its variable presentation and the lack of objective measurement tools.(1)However, a considerable body of evidence now supports its existence.(2) This article aims to help pharmacists treat fibromyalgia patients with appropriate drug and nondrug therapies, as both approaches are required for successful treatment.Fibromyalgia facts Fibromyalgia is a nonprogressive, nondegenerative pain condition that may either suddenly present after an emotional or physical trauma, or develop slowly over many years.(3) The pain is diffuse and muscular in origin, with some neuropathic features (e.g., burning, shooting, numbness, tingling, electric shock-like). It affects 2%–8% of the general population, with a higher prevalence in women than men (2:1).(4) Fibromyalgia has many different symptoms (Table 1). Its presentation is not uniform, and symptoms can worsen with environmental factors (temperature/weather) and emotional or physical stress.(2-5)Table 1: Fibromyalgia symptoms and prevalence(2-5)Sleep disturbances (insomnia): 70%-90%Fatigue: 75%Chronic widespread musculoskeletal pain: Up to 30%Cognitive complaints (forgetfulness, difficulty concentrating): 76%Depression and/or anxiety disorders: 20%-86%Intolerance to hot/cold, chemicals/medications, odours, noise: VariableBalance disorders: VariableIt often takes more than two years and at least four consultations with different physicians before an individual is diagnosed with fibromyalgia.(6) Diagnosis was once performed using a physical assessment of tender points, usually by a rheumatologist. This has been replaced by a validated questionnaire (the Fibromyalgia Impact Questionnaire Revised, FIQR), which takes only a few minutes to complete.(2) Although pharmacists cannot diagnose fibromyalgia, the FIQR (https://fiqrinfo.ipage.com/FIQR%20FORM.pdf) can be provided to patients to help measure treatment progress.Pharmacologic managementGuidelines offer insight into which medications should be tried in patients with fibromyalgia (see Figure 1 example).(7,8) The underlying mechanisms in fibromyalgia are not yet understood; however, serotonin and epinephrine deficiencies appear to play a large part.(2,7) Therefore, medication trials with antidepressants have been used.Although lacking an official indication for fibromyalgia, tricyclic antidepressants (e.g., amitriptyline or nortriptyline) at low doses, or the tricyclic (muscle relaxant) cyclobenzaprine, have been used with mixed success to treat fibromyalgia pain, mood disorders and insomnia.(8) Additionally serotonin-norepinephrine reuptake inhibitors (SNRIs) (e.g., duloxetine or venlafaxine XR), usually at higher dosing ranges, can be useful if tricyclic antidepressant intolerance or side effects (e.g., anticholinergic effects, weight gain, drowsiness) are problematic.(8) Tramadol, which has mu-opioid agonist activity, also possesses SNRI activity; therefore, it is the opioid of choice in individuals with fibromyalgia.(10) Traditional opioids are not effective for fibromyalgia-related pain and may increase sensitivity to diffuse pain at high doses.(8,10) The anticonvulsants pregabalin and gabapentin are other useful therapies. They can be used in combination with an antidepressant to maximize medication therapy, but may cause additive side effects to tricyclic antidepressants, such as weight gain and drowsiness, which should be monitored.(8)Nonpharmacologic therapy – the cornerstone of treatmentAerobic exercise is the most helpful therapy for fibromyalgia. It can be introduced gradually, with or without the assistance of a physiotherapist.(8) Therapies such as hydrotherapy (swimming), meditation, mindfulness, yoga/tai chi and psychological therapy all improve symptoms of pain, fatigue and low mood. They work best in conjunction with medication therapy.(8)Pharmacist’s role Pharmacists can make several interventions in fibromyalgia treatment. A patient that complains of persistent fatigue, diffuse widespread muscle pain that appears to change with stress or weather, and a mood disorder (depression/anxiety) may have fibromyalgia and should be referred to a physician for diagnosis.Newly diagnosed patients should be tried on the most appropriate therapy according to their symptoms. It is best to target as many symptoms as possible while using the fewest number of medications. For example, tricyclic antidepressants target a variety of symptoms (e.g., headache, insomnia, pain, depression). Additionally, certain medications are best avoided in the elderly (tricyclic antidepressants) or overweight individuals (tricyclics and pregabalin).Patients already diagnosed with fibromyalgia may have tried several guideline-recommended medications and discontinued them due to perceived sensitivities (not true allergies). Patients and prescribers should be encouraged to give these medications a fair re-trial at treatment doses (Table 2), as premature discontinuation is quite common in my experience. Patients using opioid therapy (excluding tramadol) as their main treatment should be advised to undergo a taper (unless suffering from another pain condition that responds to opioids).Lastly, even if patients have maximized drug therapy, encourage nondrug treatments (exercise and psychological therapy) as this will provide greater benefit than drugs alone.ConclusionFibromyalgia is a disabling condition that often takes many years to be diagnosed. A variety of treatments provide some of resolution of symptoms. Pharmacists can help by validating patients’ symptoms, assessing the appropriate use of medications for this condition, and emphasizing that patients explore nondrug treatments to help with their pain.Vikas Parihar, BScBiochem, BScPharm, PharmD, is a clinical pharmacist in the Michael G. DeGroote Adult Pain Clinic at McMaster University Medical Centre, and adjunct assistant clinical professor with the Faculty of Health Sciences, Department of Anesthesia at McMaster University, in Hamilton, Ont.References1. Grob GN. The rise of fibromyalgia in 20th-century America. Perspect Biol Med 2011;54:417-37.2. Borchers AT, Gershwin ME. Fibromyalgia: a critical and comprehensive review. Clin Rev Allergy Immunol 2015;49(2):100-51.3. Hauser W, Fitzcharles M. Clinical research. Facts and myths pertaining to fibromyalgia. Dialogues Clin Neurosci 2018;20(1):53-62.4. Clauw DJ. Fibromyalgia. A clinical review. JAMA 2014;311:1547-55.5. Sumpton JE, Moulin DE. Fibromyalgia. Handb Clin Neurol 2014;119:513-27.6. Choy E, Perrot S, Leon T, et al. A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Serv Res 2010;10.7. Kia S, Choy E. Update on treatment guideline in fibromyalgia syndrome with focus on pharmacology. Biomedicines 2017;5(2):20.8. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis 2017:76:318-28.9. Traynor L, Thiessen C, Traynor A. Pharmacotherapy of fibromyalgia. Am J Health Syst Pharm 2011;68:1307-19.10. National Opioid Use Guideline Group (NOUGG). Canadian guideline for safe and effective use of opioids for chronic non-cancer pain; 2010. Available from: http://nationalpaincentre.mcmaster.ca/opioid/ (accessed September 28, 2018).

Fibromyalgia: The pain condition with many faces

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