7 fibromyalgia case cederquist final · 2018-04-04 · fibromyalgia case discussion lyne,e...
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9/20/17
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Fibromyalgia Case Discussion
Lyne,eCederquistM.D.ClinicalProfessorofMedicine
UniversityofCalifornia,SanDiego
Objectives
• IdenDfychallengesofdiagnosingfibromyalgia• DiscusspracDcalapproachestotheworkup• Outlineastrategyformanagingfibromyalgia
Disclosure
• Nothingtodisclose.
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61-year-old woman with gradual onset total body pain
• Startedalmostayearago• Achy,sDffmusclepainandachyjoints.Nojointswelling,nomuscleweakness.
ShefeelsherpainisworseaQerexercising,butdoesnotimprovesignificantlywithrest.
• AccompaniedbyworseningfaDgueandpoorsleep.Shewakesupfeelingexhausted.
• HersymptomsstartedduringaperiodofextremeaddedstressatherjobasamarkeDngrepresentaDvewhichrequiredextensivetravel
• PMH:Hypertension,hypercholesterolemia,Irritablebowelsyndrome• MedicaDons:lisinopril10mgdaily,atorvastaDn40mgdaily,Metamucildaily,
prnibuprofen
61-year-old woman with gradual onset total body pain
• SocialHistory:Married,wasworkingfullDmeasamarkeDngrepresentaDveforasoQwarecompany.Quitworking3monthsagoduetoherworseningsymptoms.
• FamilyHistory:NegaDve• ReviewofSystems:– General:Noweightloss,fevers– posiDveforfeelingmoredepressedpastfewmonthsbecauseoffeelingpoorly,notbeingabletoworkorexercising,andcurbinghersocialacDviDesbecauseshedoesn’tfeelwell.
– Intermi,entabdominalcrampingwithmostlyconsDpaDon– Herhusbandreportsthatshesnores
What else would you want to know?
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What else would you want to know?
• CurrentlevelofacDvityandfuncDon?– Shenowspends50%ofthedayresDng– Shehasbeenoffworkforthepastfewmonths– Shehasstoppedexercising–sheusedtogotothegymorgoforahikeafewDmesaweekwhichsheenjoyed
• Currentdiet,nutriDon,substanceuse?– Sheeatsafairlybalanceddiet– Alcohol–2glassesofwine3-4x/week– Nosmokingordruguse– Doesnottakeanyvitaminsorsupplements
Physical Exam: • Shedoeshave14tenderpointsonherexam–bilateralcervical,anteriorcricothyroid,supraclavicular,bilateralgluteal,greatertrochanters,lateralepicondyles,andmedialknees
• Nojointswellingorwarmth• Musclestrengthandtonearenormal• Norashesorskinlesions• Neurologicexamisnormal
What would you include in your differential diagnosis?
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Differential Diagnosis
• Fibromyalgia• VitaminDdeficiency(?)• PolymyalgiarheumaDca• StaDninducedmyalgias• Sleepapnea• Depression• Hypothyroid
What labs or studies might you order?
Work up
• TSH• ESR• CPK• VitaminD• Sleepstudy• PHQ-9• DoyouorderRF,ANA?
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Patient Self Report Survey:
Self report survey:
• WidespreadPainIndex(WPI)score:14/19
• SymptomSeverityscore:7– FaDgue:severe:3(severe)– Troublethinkingorremembering:2(moderate)– Unrefreshingsleep:2(moderate)
• Co-occuringcondiDons:Headaches:1
• Depression:1TotalScore:23
Patient Self-report Survey for the Assessment of Fibromyalgia Based on
Criteria in the 2011 Modification of the ACR Preliminary Diagnostic Criteria for
Fibromyalgia. The possible score ranges from 0 to 31
points; a score ≥13 points is consistent with a diagnosis of fibromyalgia.
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All of the studies come back normal. You conclude that she has
fibromyalgia
What might be a reasonable initial treatment plan?
Fibromyalgia Initial Treatment Plan
• EducaDon!CounselpaDentindetailregardingnaturalcourseoffibromyalgia
• CounselpaDentaboutacDvitypacing• Exerciseplan• StressreducDon,mindbodypracDces–yoga,taichi,MBSR• ConsiderstaDnholiday• ProvidelistofpotenDallybeneficialvitaminsandsupplements
2-month Follow up
• SheisnowparDcipaDnginaquatherapy3x/week• ShehasbeentakingVitaminBcomplex,VitaminD1,000IU/day,magnesiumglycinate200mgbid
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She is feeling better overall, but still feels she needs more help with pain relief. Her fatigue is also better, but problematic. She is still hoping to
return to work in the next few months.
What treatments would you consider at this time?
Starting a Medication
• ConsiderSNRIifpaDenthasasignificantconcurrentmooddisorder:– DuloxeDne60-120mgdaily
– Milnacipran50mgbid
• Ifnomooddisorderbutpoorsleep,consideragabapenDnoid:– Pregabalin150mgbid– GabapenDn300-400mgDd
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Reasonable prn Medications
• Analgesic:tramadol• Musclerelaxant:cyclobenzaprine• Sleepagent:trazodone,melatonin
• Avoid:opiates,benzodiazepines,carisoprodol(Soma)
For Fatigue, Consider
• AddingamindbodypracDce:TaiChi,yoga,MBSR• TrialofaddiDonalsupplement:CarniDne2,000mg/day,D-ribose5gmsbid,CoQ10100-300mg/day,orSAMEe800mg/day
She comes back for follow-up after 2 months on pregabalin 150 mg bid, as well as recommended supplements
• Painisbe,er
• FaDgueisali,lebe,erwithsupplements,andregularpracDceofTaiChi
• Feelstoogroggyonthepregabalin• Wantstotrysomethingelse
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What might you try next?
Alternate Medications to Consider
• DuloxeDne• Milnacipran• TCA–amitriptylineornortriptyline• Lowdosenaltrexone
Patient now remembers she took duloxetine 3 years ago and had
intolerable nausea, so she does not want to try it again. She also does not want to try milnacipran for the same
reason.
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Her recent ECG revealed a prolonged QTc so you don’t want to use a TCA
You decide to do a trial of low dose
naltrexone, 4.5 mg qhs
Next 2-month follow up, her fibromyalgia treatment plan now
consists of:
• 3x/weekaquatherapy• 1x/weekTaiChiclass• AcDvitypacing–adherestoaconsistentmoderateschedule• VitaminBcomplex,VitaminD• Magnesiumglycinate,CoQ10supplement• Lowdosenaltrexone4.5mgqhs
Patient still has pain and fatigue, but manageable.
She has started looking for
part time employment
SUCCESS! (because everybody likes ahappy
ending)
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