disclosure this program was developed from an educational grant from pfizer to the university of...
TRANSCRIPT
DisclosureDisclosure
This program was developed from an educational grant from Pfizer to the University of Calgary and Université de Sherbrooke.
Faculty disclosure
Core Development Committee Core Development Committee
Dr. Christian Cloutier, Neurosurgeon, QuebecDr. Mary-Ann Fitzcharles, Rheumatologist, QuebecDr. Algis Jovaisas, Rheumatologist, Ontario Ms. Christal Lacombe, Pharmacist, AlbertaDr. Rhonda Shuckett, Rheumatologist, British ColumbiaDr. Richard Ward, Family Physician, Alberta
National CommitteeNational Committee
Dr. Brian Craig, Family Physician, New BrunswickDr. Alan Kaplan, Family Physician, OntarioDr. Bernard Martineau, Family Physician, QuebecDr. Kenneth Stakiw, Family Physician, SaskatchewanMr. Robert Thiffault, Pharmacist, Quebec
Overall Learning ObjectivesOverall Learning Objectives
Following this program, participants willDescribe the diagnosis and core symptoms of fibromyalgia (FM) Have an approach to explaining the diagnosis of FM to patientsPrescribe appropriate pharmacologic and non-pharmacologic interventions based on predominant symptoms
Menu (all related to FM)Menu (all related to FM)
Click on the name of the module you want to access
Management of PainManagement of Pain
FatigueFatigue
Sleep DisturbanceSleep Disturbance
Non-pharmacologic Interventions
1
2
3
7
DepressionDepression 4
Making the DiagnosisMaking the Diagnosis 5
““Selling” the DiagnosisSelling” the Diagnosis 6
Choice of Medical Choice of Medical TherapyTherapy 8
Incomplete Treatment Incomplete Treatment ResponseResponse 9
ObjectivesObjectives
Following this module, participants will be able to:Explain the basis of increased pain in patients with fibromyalgia (FM)Discuss the relationship between pain, fatigue and sleep disturbance in FMSuggest non-pharmacologic therapies for painPrescribe medications that improve pain in FMRecognize the role of an interdisciplinary team in FM management
• Chronic, widespread pain is the defining feature of fibromyalgia
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread PainWidespread Pain
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
• Patients describe it as physically or emotionally draining
FatigueFatigue
Core Clinical Features of FMCore Clinical Features of FM
StiffnessStiffness• Stiffness in the morning is a common
characteristic of FM
• Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation
Neurocognitive ImpairmentNeurocognitive Impairment(“Fibro Fog”)(“Fibro Fog”)
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
• Chronic, widespread pain is the defining feature of FM
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread Pain
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. Patty was advised to attend a local yoga studio, which has a special FM class. She was given a morning medication that targeted mood. As well, she was referred to a local FM support group.
Video 1Video 1
QuestionsQuestions
1. Why do patients with FM have pain?
2. What non-medication approach would you take with Patty?
3. What medical FM therapies improve pain?
4. How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM?
Take the time to answer each of the questions
Symptoms of FMSymptoms of FM
Pain, fatigue and sleep disturbance are present in at least 86% of patients*
0
20
40
60
80
100100%
96%
86%
72%
60%56%
52%46%
42% 41%
32%
20%
Muscularpain
Fatigue Insomnia Jointpains
Head-aches
Restlesslegs
Numbness and
tingling
Impairedmemory
Leg cramps
Impaired Concen-tration
Nervous-ness
Major depression
*United States dataACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web Site http://www.nfra.net/Diagnost.htm.
Pathophysiological Observations in FMPathophysiological Observations in FM
Despite extensive research, the exact cause of pain in FM is not clearly understood
PeripheralPeripheral sensitizationTemporal summation (windup) (short-term)
Spine and brainCentral sensitization (long-term)Change in grey matter volume
Descending inhibitionOther factors
Hypothalamic-pituitary-adrenal axis dysregulationSleep disturbanceCognitive effects
Staud et al. Nat Clin Pract Rheumatol. 2006;2:90-98; Henriksson. J Rehabil Med. 2003;41(suppl 41):89-94; Crofford et al. Arthritis Rheum. 2002;46:1136-1138; Vaerøy et al. Pain. 1988;32:21-26; Staud. Arthritis Res.Ther. 2006;8:208.
Key Messages for Pain Principles in FM
Key Messages for Pain Principles in FM
There is no “cure” for the painActive patient involvement: activity and non-medication approaches Important to manage patient’s expectationsNormalize sleepNormalize moodStart with medical interventions for pain that have evidence for efficacy in FM
Start low, go slow!
Target pain control that allows functionality
Non-pharmacologic TreatmentsNon-pharmacologic Treatments
Patient educationConflicting evidence but some studies have shown improvements in pain, sleep, fatigue and quality of life
Cognitive-behavioural therapyPositive effects on coping with and control over pain
• Not proven to improve pain Proven to improve physical functionShould be done by a trained professional
Aerobic and strengthening exercisesReduce pain, increase self-efficacy, improve quality of life and reduce depression Aerobic exercise should be of low to moderate intensity, 2–5 times/week
Goldenberg et al. JAMA. 2004;292:2388-2395.Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:873-886.Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:857-871.
Modulating Factors of FM Syndrome Pain
Modulating Factors of FM Syndrome Pain
Wallace et al. Fibromyalgia and Other Central Pain Syndromes. Lippincott Williams & Wilkins; 2005:126.
Factors Mean %Exacerbating Factors
Weather (cold/humid) 65
Poor sleep 70
Anxiety/stress 61
Physical inactivity 49
Noise 22
Relieving Factors
Local heat 58
Rest 54
Moderate activities 46
Massage 40
Stretching exercises 43
Sleep interference can directly result from and/or contribute to FM
Psychological symptoms are
strongly associated with FM
Management strategy for FM patients
is to improve overall patient functionality
Management strategy for FM patients
is to improve overall patient functionality
Adapted from Argoff. Clin J Pain. 2007;23:15-22.
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Paradigm of pain Paradigm of pain
FunctionalImpairmentand Fatigue
Pain Related
Sleep Deprivation and PainSleep Deprivation and Pain
Activates, maintains central nervous system (CNS) areas responsible for awake state
Dampens areas responsible for initiation and maintenance of sleep
May impair healing, leading directly to pain
Affects CNS areas responsible for coping mechanisms useful for dampening pain experience
Chronic painChronic pain Lack of sleepLack of sleep
Sleep disturbances may lead directly to more pain, and indirectly to a heightening of the pain experience through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133.
Best Evidence: FM Pain MedicationBest Evidence: FM Pain MedicationMedication Mechanism of
ActionEffect on Pain
Effect on Other Symptoms
Off/on Label Indication
Comments Starting Dose and Titration
Usual Maintenance Dose
Amitriptyline (desipramine, doxepin, nortriptyline)
TCA(NE > 5HT)
+ Sleep, anxiety
Off Poor long term, doxepin seldom recommended, desipramine may cause insomnia (administer in morning), not well tolerated in this population
10-25 mg/day Increase weekly by 10 mg/day
50-150 mg/day
Cyclobenzaprine Muscle relaxant (NE)
+ Sleep Off Poor long term 10 mg 3 times/day 10 mg 3 times/day (range of 20-40 mg/day in divided doses, max 60 mg/day)
Duloxetine SNRI +++ Depression, anxiety
On 60 mg/day
(can start at 30 mg for tolerability reasons with target of 60 mg/day in 1-2 weeks)
60-120 mg/day
Gabapentin 2 binding: ↓neuronal excitation
++ Sleep, anxiety
Off 300 mg 3 times/day; increase with 300- or 400-mg capsules, or 600- or 800-mg tablets 3 times/daily
3 times/day up to 1800 mg/day
Pramipexole Dopamine agonist
+ Fatigue Off Limited population studied
Start 0.375 mg/day in 3divided doses; increase gradually no more frequently than every 5-7 days
1.5 to 4.5 mg/day in equally divided doses 3 times/day
Pregabalin 2 binding: ↓neuronal excitation
+++ Sleep, anxiety
On 150 mg/day in 2 divided doses; increase by 150 mg/day after 1 week
300-450 mg in 2 divided doses
Tramadol Opioid agonist SNRI
++ Off 25 mg/day; increase by 25 mg/day every 3 days to 50 mg 4 times/day
50-100 mg 4 times/day
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant
(alphabetical order)(alphabetical order)
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
No/Poor Evidence: FM Pain Medication No/Poor Evidence: FM Pain Medication
Medication Mechanism of Action
Rationale for Use Concern for Use
Benzodiazepines GABA increase Anxiety AddictionSide effects
Cannabinoids CB 1 receptor agonist
Improves sleep Lack of effectiveness in FM painSide effects
NSAIDs Prostaglandin inhibition
Analgesia NSAID-related side effects
Opioids Opioid receptor agonists
Analgesia AddictionSide effectsSee new national guidelines
NSAID, non-steroidal anti-inflammatory drug
(alphabetical order)(alphabetical order)
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
Pain is the most common symptom of FMSet realistic treatment goals Use non-pharmacologic treatments firstUse medical therapies that target pain and have evidence for efficacy in FM as first-line pharmacotherapyBalance medication side effects and risk with optimizing function
Menu
ObjectivesObjectives
Following this module, participants will be able to: Provide a differential diagnosis of fatigue in patients with fibromyalgia (FM)Prescribe therapies that will improve fatigue in FMAssist patients in establishing reasonable treatment goalsRecognize the role of an interdisciplinary team in FM management
Core Clinical Features of FMCore Clinical Features of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
• Chronic, widespread pain is the defining feature of FM
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread PainWidespread Pain
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
• Patients describe it as physically or emotionally draining
FatigueFatigue
StiffnessStiffness• Stiffness in the morning is a common
characteristic of FM
• Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation
Neurocognitive ImpairmentNeurocognitive Impairment(“Fibro Fog”)(“Fibro Fog”)
• Patients describe it as physically or emotionally draining
Fatigue
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. Patty signed up at a local gym to take aerobic exercise classes at your suggestion. She was given a bedtime medication to improve her sleep and referred to a website that provides information for patients with FM.
Video 1Video 1
QuestionsQuestions
1. In patients with an established diagnosis of FM, what factors should be considered when evaluating fatigue?
2. What non-medication approach would you take with Patty?
3. What FM medications target fatigue?
4. How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM? What other healthcare professional could help?
Take the time to answer each of the questions
Symptoms of FMSymptoms of FM
Pain, fatigue and sleep disturbance are present in at least 86% of patients*
0
20
40
60
80
100100%
96%
86%
72%
60%56%
52%46%
42% 41%
32%
20%
Muscularpain
Fatigue Insomnia Jointpains
Head-aches
Restlesslegs
Numbness and
tingling
Impairedmemory
Leg cramps
Impaired Concen-tration
Nervous-ness
Major depression
*United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Things to Consider when FM Patients Complain of Fatigue
Things to Consider when FM Patients Complain of Fatigue
1. Sleep disturbance2. Uncontrolled pain3. Depression4. Unrealistic expectations5. “Stress” caused by illness6. Medication side effects
(especially polypharmacy)7. Deconditioning8. Unrecognized new illness*
* Avoid the trap of re-investigating the patient with firmly diagnosed FM, but remember: eventually all FM patients will get another disease!
1. Musculoskeletal (19.4%)2. Psychosocial (16.5%)3. Gastrointestinal (8.1%)4. Neurological (6.7%)5. General (4.9%)6. Respiratory (4.9%)7. Endocrine (2.8%)8. Cardiovascular (1.9%)9. Menopause (1.1%)10. Malignancy (.7%)
46.9% of those with the initial presentation of fatigue and with no diagnosis made at the time of presentation had, at the end of one year, one or more of these diagnoses that could possibly be the cause of their fatigue.
Fatigue in Primary Care – One-Year Follow-Up
Fatigue in Primary Care – One-Year Follow-Up
Note that of musculoskeletal complaints, most were deemed non-specific.
Documentation at initiation of study indicated that 24.1% of patients had depressive symptoms. Diagnosis of depression was made in 4.9% of subjects at one year.
Nijrolder et al. CMAJ. 2009;181:683-687.
Sleep interference can directly result from and/or contribute to FM
Psychological symptoms are
strongly associated with FM
Management strategy for FM patients
is to improve overall patient functionality
Management strategy for FM patients
is to improve overall patient functionality
Adapted from Argoff. Clin J Pain. 2007;23:15-22
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Paradigm of pain Paradigm of pain
FunctionalImpairmentand Fatigue
Pain Related
Sleep Deprivation and PainSleep Deprivation and Pain
Activates, maintains central nervous system (CNS) areas responsible for awake state
Dampens areas responsible for initiation and maintenance of sleep
May impair healing, leading directly to pain
Affects CNS areas responsible for coping mechanisms useful for dampening pain experience
Chronic painChronic pain Lack of sleepLack of sleep
Sleep disturbances may lead directly to more pain, and indirectly to a heightening of the pain experience through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133
Utility of FM Medications Targeting Fatigue
Utility of FM Medications Targeting Fatigue
There are no generally accepted, on-label medications that improve
the fatigue associated with FM
Physical activity is the only non-pharmacologic strategy proven
to reduce fatigue
What is helpful for complaints of fatigue?What is helpful for complaints of fatigue?
Improvement of sleep hygieneModerate physical activityPacingRealistic goal settingHealthy eatingCognitive behavioral therapy (CBT)
Lera et al. J Psychosom Res. 2009;67:433-441.Rossy et al. Ann Behav Med. 1999;21:180-191.Williams. Best Pract Res Clin Rheumatol. 2003;17:649-665.
Medications with Anti-fatigue Properties Medications with Anti-fatigue Properties
Medication Mechanism of Action
Effect on Fatigue
Effect on Other Symptoms
Comments
Bupropion NEDopamine
- Depression More “energizing” antidepressant
Duloxetine SNRI + Pain, depression, anxiety
Improvement in fatigue as secondary endpoint
Modafinil DopamineNE
+ Open label small study
Pramipexole Dopamine agonist
+ Pain Off label - limited population studied
Stimulants (methylphenidate, dextroamphetamine)
NEDopamine
- No evidenceAddiction properties so caution
(alphabetical order)(alphabetical order)
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
When fatigue is the primary complaint, evaluate sleep and pain control, and rule out depressionUse of medications may improve fatigueHelp patients set realistic goals for improvement of fatigueImportant role of non-pharmacologic interventions, especially physical activities
Menu
ObjectivesObjectives
Following this module, participants will be able to: Recognize the relationship between sleep restoration and symptom improvement in patients with fibromyalgia (FM)Provide non-pharmacologic therapies to improve sleep disturbancePrescribe medications that target sleep and other FM symptomsRecognize the role of the interdisciplinary team in FM management
Core Clinical Features of FMCore Clinical Features of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
• Chronic, widespread pain is the defining feature of FM
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread PainWidespread Pain
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
• Patients describe it as physically or emotionally draining
FatigueFatigue
StiffnessStiffness• Stiffness in the morning is a common
characteristic of FM
• Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation
Neurocognitive ImpairmentNeurocognitive Impairment(“Fibro Fog”)(“Fibro Fog”)
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. Patty was advised to attend a local yoga studio, which has a special FM class. She was given a morning medication that targeted mood and pain. She was encouraged to review a website that provides information for patients with FM.
Video 1Video 1
QuestionsQuestions
1. What elements should you consider when evaluating Patty’s sleep problems?
2. What non-medication approach would you take with Patty?
3. What FM medications improve sleep problems?
4. How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM?
Take the time to answer each of the questions
Symptoms of FMSymptoms of FM
Pain, fatigue and sleep disturbance are present in at least 86% of patients*
0
20
40
60
80
100100%
96%
86%
72%
60%56%
52%46%
42% 41%
32%
20%
Muscularpain
Fatigue Insomnia Jointpains
Head-aches
Restlesslegs
Numbness and
tingling
Impairedmemory
Leg cramps
Impaired Concen-tration
Nervous-ness
Major depression
* United States data
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Pain
Poor sleep hygiene
Medication side effects (including caffeine)
Anxiety/depression/bipolar disorder
Other sleep disorders (restless leg syndrome, obstructive sleep apnea, etc.)
Differential Diagnoses to Consider with Sleep Disorders
Differential Diagnoses to Consider with Sleep Disorders
Sleep interference can directly result from and/or contribute to FM
Psychological symptoms are
strongly associated with FM
Management strategy for FM patients
is to improve overall patient functionality
Management strategy for FM patients
is to improve overall patient functionality
Adapted from Argoff. Clin J Pain. 2007;23:15-22.
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms
Paradigm of pain Paradigm of pain
FunctionalImpairmentand Fatigue
Pain Related
Sleep Deprivation and PainSleep Deprivation and Pain
Activates, maintains central nervous system (CNS) areas responsible for awake state
Dampens areas responsible for initiation and maintenance of sleep
May impair healing, leading directly to pain
Affects CNS areas responsible for coping mechanisms useful for dampening pain experience
Chronic painChronic pain Lack of sleepLack of sleep
Sleep disturbances may lead directly to more pain, and indirectly to a heightening of the pain experience through impairment of usual adaptive mechanisms.
Call-Schmidt, Richardson. Pain Manag Nurs 2003;4:124-133.
Pain Leads to Sleep DisruptionPain Leads to Sleep Disruption
Result of noxious pain stimuli = arousalDecrease in delta wavesIncrease in alpha waves
In FM: the structure of the sleep is modified and there is fragmentation of sleep
Drewes et al. Sleep. 1997;20:632-640.
Non-pharmacologic Interventions to Improve Sleep
Non-pharmacologic Interventions to Improve Sleep
1. Avoid stimulants
2. Regular time to go to bed and to rise
3. Avoid napping through day
4. Regular AM exercise
5. Bed is for sleep and sex
6. Relaxation before bed
7. Sleep handout for patients
www.tufts.edu/med/phfm/pdf/fm-handouts/SleepHygiene.pdf
Medications and Effects on SleepMedications and Effects on Sleep
Medication Effect on Sleep Effect on Pain
Amitriptyline (desipramine, doxepin, nortriptyline)
+++ + (poor long-term)
Atypical antipsychotics +++ ±
Benzodiazepines +++ -
Cannabinoids +++ +
Cyclobenzaprine +++ + (poor long-term)
Duloxetine + +++
Gabapentin ++ ++
Pregabalin +++ +++
Zopiclone +++ -
(alphabetical order)(alphabetical order)
Evidence for effect on sleep is mostly within non-pain patients and has been collected by polysomnography. The only evidence from patients with pain is with pregabalin through patient diaries and Medical Outcomes Study Sleep scores
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
Rule out secondary causes of sleep disordersConsider lifestyle modification as a first step to manage sleep problemsConsider pain/sleep/fatigue cycle when considering therapiesUse medical therapies that target sleep when it is prevalent disabling symptom
Menu
ObjectivesObjectives
Following this module, participants will be able to:Differentiate fibromyalgia (FM) from depressionPrescribe therapies that will improve both FM and depressionHave an approach to explaining depression and FM to patientsUse an interdisciplinary team to manage patients with FM
Core Clinical Features of FMCore Clinical Features of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
• Chronic, widespread pain is the defining feature of FM
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread PainWidespread Pain
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
• Patients describe it as physically or emotionally draining
FatigueFatigue
StiffnessStiffness• Stiffness in the morning is a common
characteristic of FM
• Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation
Neurocognitive ImpairmentNeurocognitive Impairment(“Fibro Fog”)(“Fibro Fog”)
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. Patty was referred to a “Living with FM” lifestyle program run by a local physiotherapist. She was advised to work on lifestyle and sleep hygiene, and to use a simple over-the-counter analgesic for pain control. She presents for follow-up complaining that the interventions are “not effective.”
Video 1Video 1
QuestionsQuestions
1. Is FM just depression with pain?2. What treatment modalities may be indicated in
this patient?3. How would you convince Patty that an
antidepressant medication would be a good choice?
4. How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM?
Take the time to answer each of the questions
Symptoms in FM SyndromeSymptoms in FM SyndromeSYMPTOMS MEAN
(%)
Musculoskeletal
Pain at multiple sites 100
Stiffness 76
“Hurt all over” 62
Swollen feeling in tissues 52
Non-musculoskeletal
General fatigue 87
Morning fatigue 75
Sleep difficulties 72
Paresthesia 54
Dizziness/vertigo 59
Tinnitus 17
Sicca symptoms 15
Raynaud phenomenon 14
SYMPTOMS MEAN (%)
Non-musculoskeletal
Anxiety 60
Mental stress 61
Depression 37
Cognitive dysfunction 61
Selected Associated Syndromes
Headaches 54
Dysmenorrhea 43
Irritable bowel syndrome 38
Restless legs syndrome 31
Female urethral syndrome
15
Wallace et al. Fibromyalgia and Other Central Pain Syndromes. Lippincott Williams & Wilkins; 2005:126.
Anxiety disorder
Any psychiatric disorder
Mood disorder
100
80
60
40
20
0
100
80
60
40
20
0
How Patients with Psychiatric Disorders Initially Present to
Primary Care Physicians1
How Patients with Psychiatric Disorders Initially Present to
Primary Care Physicians1
Psychological
83%
Somatic
17%
Strong Correlation Between Number of Physical Symptoms and
Prevalence of Psychiatric Disorders2
Strong Correlation Between Number of Physical Symptoms and
Prevalence of Psychiatric Disorders2
The more physical complaints there are, the more likely there is a psychiatric problem.
Pat
ien
ts w
ith
psy
chia
tric
dis
ord
ers
(%)
Number of physical complaints 2-3 4-5 6-8 ≥9
Most people with psychological problems go to their family doctor with a physical complaint rather than recognizing that they have a form of mental distress.
1. Kirmayer et al. Am J Psychiatry. 1993;150:734-741. 2. Kroenke et al. Arch Fam Med. 1994; 3:774-779.
0-1
Symptom Psychiatric Healthy
Tired, lack of energy 85% 40%
Headache, head pains 64% 48%
Dizzy or faint 60% 14%
Parts of body felt weak 57% 23%
Muscle pains, aches, rheumatism 53% 27%
Stomach pains 51% 20%
Chest pains 46% 14%
Adapted from Kellner R and Sheffield BF. Am J Psychiatry. 1973;130:102-105.
Somatic SymptomsCommon in Psychiatric Patients
Somatic SymptomsCommon in Psychiatric Patients
Maintain a High Index of Suspicion for the Diagnosis of Major Depressive Disorder
Maintain a High Index of Suspicion for the Diagnosis of Major Depressive Disorder
In patients with:Multiple physical symptomsFrequent visits and thick chartsPoor sleep, fatigue Chronic pain (including FM, migraines, irritable bowel syndrome)Anxiety disordersSubstance-use disordersAttention-deficit/hyperactivity disorderType II diabetes, ischemic heart disease, cerebrovascular accidents, cancer, osteoporosis
Mood Disorders in FMMood Disorders in FM
At time of diagnosis, approximately 20%–40% of individuals with FM have an identifiable current mood disorder (e.g., depression or anxiety)
Lifetime prevalence of depression: 74%
Lifetime prevalence of anxiety disorder: 60%
In many cases, depression or anxiety may be the result of chronic pain
Katon et al. Ann Intern Med. 2001;134:917-925.Boissevain et al. Pain. 1991;45:227-238.Boissevain et al. Pain. 1991;45:239-248.Giesecke et al. Arthritis Rheum. 2003;48:2916–2922.Arnold et al. Arthritis Rheum. 2004;50:944–952.Fishbain et al. Clin J Pain. 1997;13:116–137.
Strategy for Explaining DepressionStrategy for Explaining Depression
Reinforce neurobiological basis of depression
Acknowledge that chronic pain and depression frequently co-exist
Use the symptom complex for depression –SIGECAPS – to help patients understand symptom grouping
Encourage bibliotherapy to reinforce concepts
Use other members of healthcare team to assist in psychoeducation
SIGECAPS, mnemonic mnemonic for symptoms of major depression and dysthymia (sleep disorder, interest deficit, guilt, energy deficit, concentration deficit, appetite disorder, psychomotor retardation or agitation, suicidality)
Non-pharmacologic TreatmentNon-pharmacologic Treatment
Evidence for effectiveness of cognitive behavioral therapy (CBT) for both depression and FM
Bennett et al. Nat Clin Pract Rheumatol. 2006;2:416-424.Whitfield et al. Advances Psychiat Treat. 2003;9:21-30.
Medications for FM that Have Mood Regulation and Anxiolytic PropertiesMedications for FM that Have Mood Regulation and Anxiolytic Properties
Medication Mechanism of Action
Effect on Mood/Anxiety
Effect on Other Symptoms
Off/on- Label Indication For FM
Comments
Amitriptyline(desipramine, doxepin, nortriptyline)
TCA(NE > 5HT)
+ Pain, sleep Off FM doses < usual antidepressant dose
Bupropion Atypical anti-depressant
++ Fatigue Off More “energizing” antidepressant
Duloxetine SNRI +++ Pain On
Gabapentin 2 binding: ↓neuronal excitation
++ Pain, sleep Off Address anxiety reduction properties
Pregabalin 2 binding: ↓neuronal excitation
+++ Pain, sleep On Address anxiety reduction properties
Sertraline SSRI ++ Pain Off Compared versus physical therapy
Venlafaxine SNRI > SSRI ++ Pain Off Open-label small studies, limited effect on FM pain
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant
(alphabetical order)(alphabetical order)
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
FM is common, depression is common. They frequently occur together but are separate disorders
Patient education is key
Use an interdisciplinary team and multimodal therapies to help treat FM and comorbid depression
Use pharmacologic and non-pharmacologic (especially CBT) strategies
Therapies that may treat both include CBT and antidepressants with analgesic properties
Menu
ObjectivesObjectives
Following this module, participants will be able to:
Give the prevalence demographics of fibromyalgia (FM)Make a diagnosis of FMOrder appropriate investigations for patients with suspected FMProvide a differential diagnosis for patients presenting with widespread pain, fatigue and sleep problems
Case StudyCase Study
Patty is a 32-year-old woman in your practice History:
Under your care for 10 years
Unremarkable past history
Slipped on ice 4 months ago and has had progressive generalized pain and fatigue
Saw a locum 2 weeks ago who ran a battery of tests for multiple symptoms of generalized pain, fatigue and sleep problems
Video 1Video 1
QuestionsQuestions
1. What is the incidence and gender distribution of FM?
2. How do you make the diagnosis of FM?
3. What are the differential diagnoses in this patient?
4. What investigations would you have ordered 2 weeks ago?
Take the time to answer each of the questions
Prevalence of FMPrevalence of FM
FM occurs in all ages, both sexes and all cultures, but occurs more frequently in:
Women Patients between the ages of 35–60 years
In Canada:FM affects an estimated 4.9% of adult women and 1.6% of adult men Female-to-male ratio of approximately 3:1
Cardiel et al. Clin Exp Rheumatol. 2002;20:617-624; Carmona et al. Ann Rheum Dis. 2001;60:1040-1045; Lawrence et al. Arthritis Rheum. 1998;41:778-799; Lindell et al. Scand J Prim Health Care. 2000;18:149-153; Neumann et al. Curr Pain Headache Rep. 2003;7:362-368; Prescott et al. Scand J Rheumatol. 1993;22:233-237; White et al. J Rheumatol. 1999; 26:1570-1576; Wolfe F. J Musculoskeletal Pain. 1993;3:137-148; Wolfe et al. Arthritis Rheum. 1995;38:19-28;.
Core Clinical Features of FMCore Clinical Features of FM
ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.
• Chronic, widespread pain is the defining feature of FM
• Patient descriptors of pain include: aching, exhausting, nagging, and hurting
• Presence of tender points
Widespread PainWidespread Pain
• Characterized by non-restorative sleep and increased awakenings
• Abnormalities in the continuity of sleep and sleep architecture
Sleep DisturbanceSleep Disturbance
• Patients describe it as physically or emotionally draining
FatigueFatigue
StiffnessStiffness• Stiffness in the morning is a common
characteristic of FM
• Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation
Neurocognitive ImpairmentNeurocognitive Impairment(“Fibro Fog”)(“Fibro Fog”)
Symptoms of FMSymptoms of FM
Pain, fatigue and sleep disturbance are present in at least 86% of patients*
*United States data
0
20
40
60
80
100100%
96%
86%
72%
60%56%
52%46%
42% 41%
32%
20%
Muscularpain
Fatigue Insomnia Jointpains
Head-aches
Restlesslegs
Numbness and
tingling
Impairedmemory
Leg cramps
Impaired Concen-tration
Nervous-ness
Major depression
ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.
Mood Disorders in FMMood Disorders in FM
At time of diagnosis, approximately 20%-40% of individuals with FM have an identifiable current mood disorder (e.g., depression or anxiety)
Lifetime prevalence of depression: 74%
Lifetime prevalence of anxiety disorder: 60%
In many cases, depression or anxiety may be the result of chronic pain
Arnold et al. Arthritis Rheum. 2004;50:944–952; Boissevain et al. Pain. 1991;45:227-238; Boissevain et al. Pain. 1991;45:239-248; Fishbain et al. Clin J Pain. 1997;13:116–137; Giesecke et al. Arthritis Rheum. 2003;48:2916–2922; Katon et al. Ann Intern Med. 2001;134:917-925.
StressorsStressors
Some triggering event may trigger FM but is not a prerequisite
In many cases, onset of FM is gradual, with no identifiable trigger
Stressors that may trigger FM
Peripheral pain syndromes, physical trauma, infections (e.g., parvovirus, Epstein-Barr virus, Lyme disease, Q fever), psychological stress/distress, including sleep disturbances
The development of FM after a precipitating event may represent the onset of a prolonged and disabling pain syndrome with considerable social and economic implications
Greenfield et al. Arthritis Rheum. 1992;35:678-681.
McLean et al. Med Hypotheses. 2004;63:653-658.
Trigger Factors Associated Factors*
Cold 0 15Stress 9 35Emotions 5 35Overwork 0 22Trauma 24 24Surgery 4 13Death in the family 0 13Family problems 2 25Fatigue 0 23No cause/association 55 5
FM as a Consequence of Trauma
FM as a Consequence of Trauma
Factors Triggering FM or Associated with its Onset (n=136)
In most cases of FM, there is no predisposing trigger.
Adapted from Wolfe F. Am J Med. 1986;81:7-14.
*More than one factor possible for the same patient
Diagnosing FM: Overview
Diagnosing FM: Overview
Patient history of FM or related conditionsPersonal historyFamily history
Physical examinationMost important to rule out other conditions
Differential diagnosisClinical/laboratory evaluation to exclude other conditions such as:
• Osteoarthritis, rheumatoid arthritis, polymyalgia rheumatica (PMR), hypothyroidism, lupus and Sjögren’s syndrome
Note: Extensive lab evaluation is usually not necessary to rule out FM, In some cases, a thyroid-stimulating hormone test may be called for. PMR is usually not a problem as it seldom occurs under the age of 60, whereas the onset of FM after 65 is rare.
Mease. J Rheumatol. 2005;32(suppl 75):6-21; Wolfe et al. Arthritis Rheum. 1990;33:160-172.
Evolution of FM DiagnosisEvolution of FM Diagnosis
Evaluation of tender points
Identification of symptoms complex
New Canadian guidelines being developed
Assessment of FM: American College of Rheumatology (ACR)
Classification Criteria (1990)
Assessment of FM: American College of Rheumatology (ACR)
Classification Criteria (1990)
History of widespread pain that has been present for at least 3 months (ALL of the following should be present):
Pain on both sides of the bodyPain above and below the waistAxial skeletal painPain in at least 11 of 18 tender point sites on digital palpation
Wolf et al. Arthritis Rheum. 1990;33:160-172.
ACR criteria are both sensitive (88.4%) and specific (81.1%)
ACR New Proposed Diagnostic Criteria for FM – 2010 (1)
ACR New Proposed Diagnostic Criteria for FM – 2010 (1)
FM can be diagnosed if:
Symptoms for at least 3 months
No other condition to explain pain
Pain + associated symptoms
Wolfe et al. Arthritis Care Res (Hoboken). 2010;62:600-610.
ACR New Proposed Diagnostic Criteria for FM – 2010 (2)
ACR New Proposed Diagnostic Criteria for FM – 2010 (2)
Associated symptoms include:
Unrefreshed sleep
Cognitive symptoms
Fatigue
Other somatic symptoms
Wolfe et al. Arthritis Care Res (Hoboken). 2010;62:600-610.
SummarySummary
FM is a common disease of middle age with a female-to-male ratio of 3:1Simple investigations and history will exclude other rheumatologic or psychiatric conditionsThe 4 cardinal symptoms of FM include widespread pain, fatigue, sleep disturbance and cognitive slowingThe current diagnosis of FM is based on widespread pain plus associated symptom cluster with a physical exam to exclude other conditions
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ObjectivesObjectives
Following this module, participants will be able to : Explain the known pathophysiology of fibromyalgia (FM)Provide the natural history of FMNegotiate and explain the diagnosis of FMUse multidisciplinary and other resources to help educate patients around the diagnosis of FM
Case StudyCase Study
Patty is a 32-year-old woman in your practiceHistory:
Under your care for 10 yearsUnremarkable past historySlipped on ice 4 months ago and has had progressive generalized pain and fatigueSaw a locum 2 weeks ago who ran a battery of tests for multiple symptoms of generalized pain, fatigue and sleep problemsClinical exam confirms diagnosis of FM
Video 1Video 1
QuestionsQuestions
1. What is FM? How would you explain it to Patty?
2. What is the natural history of FM?
3. Is it better to “label” Patty with the diagnosis of FM?
4. What other strategies could you use to educate Patty about the disease?
Take the time to answer each of the questions
Pathogenesis of FM: Overview
Pathogenesis of FM: Overview
FM is a condition of global dysregulation of pain processing Central sensitization is one component
Mechanisms of central sensitization
Excitatory mechanismsExcitatory mechanisms
Inhibitory mechanismsInhibitory mechanisms
Price DD, Staud R. J Rheumatol. 2005;32 (Suppl 75):22-28.
Pathophysiological Changes in FM
Pathophysiological Changes in FM
Increased levels of substance P (>3x) in patients with FM
Functional magnetic resonance imaging (fMRI) studies show a marked regional increase in cerebral blood flow following a painful stimulus in patients with FM compared to controls not suffering FM
Deficit in the endogenous pain inhibitory systems noted in FM patients
Vaerøy et al. Pain. 1988;32:21-26.; Russell et al. Arthritis Rheum. 1994;37:1593-1601. ; Russell et al. In: Russell, ed. Myopain ’95: Abstracts from the 3rd World Congress on Myofascial Pain and Fibromyalgia. San Antonio, Tex; July 30-August 3, 1995.Gracely et al. Arthritis Rheum. 2002;46:1333-1343.; Julien et al. Pain. 2005;114:295-302.
Diagnosis Can Improve Patient Satisfaction
Diagnosis Can Improve Patient Satisfaction
Diagnosis of FM improves health satisfaction
White et al conducted a prospective, community comparison of FM patients in Canada that revealed significantly improved scores 36 months post-diagnosisPatients self-reported health satisfaction on a 5-point Likert scale
Improvement in Patient Health Satisfaction
Pat
ient
hea
lth s
atis
fact
ion
3
2.2*
0
1
2
3
4
Baseline Post-diagnosis
Imp
rove
men
tIm
pro
vem
ent
5
*Statistically significant versus baseline (confidence interval -1.2, -0.4)
Goldenberg et al. JAMA. 2004;292:2388-2395. White et al. Arthritis Rheum. 2002;47:260-265.
Health Economic Consequences Related to the Diagnosis of FM
Health Economic Consequences Related to the Diagnosis of FM
Tests and Imaging Referrals
General Practitioner Visits Drugs
Annemans et al. Arthritis Rheum 2008;58:895-902.
United Kingdom figures
Fate of Patients with FMFate of Patients with FM
Reassure patients that FM is not progressive and that symptoms remain stable over time1
50% were moderately to greatly improved (3 year follow-up)2
• The baseline predictors for a favorable outcome: younger age and less sleep disturbance2
Successful management requires an upbeat, optimistic approach and EARLY initiation of effective, individualized therapy
Therefore, it is important to manage patient’s expectations
1. Kennedy et al. Arthritis Rheum. 1996;39:682-685.2. Fitzcharles et al. J Rheumatol. 2003;30:154-159.
Video 2Video 2
Video de-briefVideo de-brief
Some Tips on Providing the DiagnosisSome Tips on Providing the Diagnosis
Be specific about the diagnosis
Be positive about the diagnosis
Promote and encourage patient self-efficacy around the disease but . . .
Set realistic expectations
Emphasize no cure but improved control of symptoms usually possible
Active treatments generally superior to passive treatments
Other Useful Websites/Patient InformationOther Useful Websites/Patient Information
National ME/FM Action Network:http://www.mefmaction.net
Arthritis Society of Canada: www.arthritis.ca Patient workbooks/materials
Starlanyl D, Copeland ME. Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual. 2nd ed. Oakland, CA : New Harbinger Publications; 2001.Fennell PA. The Chronic Illness Workbook: Strategies And Solutions for Taking Back Your Life. 2nd ed. Latham, NY: Albany Health Management Publishing; 2007. Bested AC, Logan AC. Hope and Help for Chronic Fatigue Syndrome and Fibromyalgia. 2nd ed. Nashville, TN: Cumberland House; 2008.
Local ResourcesLocal Resources
[Facilitators to include list of local FM resources for patients/physicians]
SummarySummary
FM is a neurobiological dysfunctionProviding a positive diagnosis improves health outcomes and reduces costsThe natural history of FM is variable. Significant numbers of patients will improveUse Internet and written resources and other members of a multidisciplinary team to educate patients
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ObjectivesObjectives
Following this module, participants will be able to:Assess motivation in patients with fibromyalgia (FM)Use simple strategies to increase patients’ readiness to incorporate non-pharmacologic and lifestyleGive evidence-based, non-pharmacologic interventions as treatment for FMRecognize the role of an interdisciplinary team in FM management
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. Patty was advised to attend a local “new movement class” targeting de-conditioned patients to increase physical activity. She was also prescribed a medication that would target pain – her most disabling symptom.
Video 1Video 1
QuestionsQuestions
1. What non-pharmacologic interventions have been shown to help with FM?
2. How might you help to motivate Patty?
3. How could your interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM?
Take the time to answer each of the questions
Management of FM:Recommended Treatment Approach
Management of FM:Recommended Treatment Approach
Multidisciplinary therapy individualized to patients’ symptoms and presentation is recommended A combination of non-pharmacologic and pharmacologic therapies may benefit most patients
*Limited evidence for efficacy existsBalneotherapy: treatment of disease or health conditions by bathing
Non-pharmacologic
Aerobic exerciseCognitive behavioral therapy (CBT)Patient educationStrength trainingAcupuncture* Biofeedback* Balneotherapy*
Goldenberg et al. JAMA. 2004;292:2388-2395.
Non-pharmacologic Treatments with Demonstrated Efficacy Currently in Use
Non-pharmacologic Treatments with Demonstrated Efficacy Currently in Use
CBTPositive effects on coping with and control over pain
• Not proven to improve pain Proven to improve physical functionShould be done by a trained professional
Aerobic and strengthening exercisesReduce pain, increase self-efficacy, improve quality of life and reduce depression Aerobic exercise should be of low-to-moderate intensity, 2–5 times/week
Patient educationConflicting evidence but some studies have shown improvements in pain, sleep, fatigue and quality of life
Goldenberg et al. JAMA. 2004;292:2388-2395.Brosseau L, et al. Phys Ther. 2008;88:857-71. Brosseau L, et al. Phys Ther. 2008;88:873-86.
Alternative/Chiropractic treatments for FM
Alternative/Chiropractic treatments for FM
Strong evidence supports aerobic exercise and CBT
Moderate evidence supports massage, muscle strength training, acupuncture and spa therapy (balneotherapy)
Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs and dietary modification
Schneider et al. J Manipulative Physiol Ther. 2009;32:25-40.
Useful Websites/Patient InformationUseful Websites/Patient Information
National ME/FM Action Network:http://www.mefmaction.net
Arthritis Society of Canada: www.arthritis.ca Patient workbooks/materials:
Starlanyl D, Copeland ME. Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual. 2nd ed. Oakland, CA : New Harbinger Publications; 2001.Fennell PA. The Chronic Illness Workbook: Strategies And Solutions for Taking Back Your Life. 2nd ed. Latham, NY: Albany Health Management Publishing; 2007. Bested AC, Logan AC. Hope and Help for Chronic Fatigue Syndrome and Fibromyalgia. 2nd ed. Nashville, TN: Cumberland House; 2008.
Local resources
Helping patients embrace lifestyle choices — improving self-efficacyHelping patients embrace lifestyle choices — improving self-efficacy
Conviction and Confidence:A Model for Successful Interventions
Conviction and Confidence:A Model for Successful Interventions
Patient conviction (i.e., sense of the patient’s personal, emotional recognition of the benefits of changing a behaviour)
“Is increasing your physical activity a priority for you?”
Patient confidence (i.e., sense of the patient’s ability to modify a behaviour)
“If you did decide to become physically active, how confident are you that you would be able to follow though?”
Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press; 1991.
LACK OF KNOWLEDGE
CYNICISM
FRUSTRATION
SKEPTICISM
C O N F I D E N C E
C O
N V
I C
T I
O N
UNWAVERINGPOWERLESS
AM
BIV
ALE
NT
CO
NV
INC
ED
0 10
SUCCESS
EMPOWERED(B
enef
its)
(Barriers)
Conviction – Confidence ModelConviction – Confidence Model10
Adapted from Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.; Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press; 1991.
How to Increase Conviction How to Increase Conviction
Get patients to articulate benefits of change
Get patients to articulate benefits of change
How to Increase Confidence How to Increase Confidence
Identify barriers to change and help patients overcome those barriers by identifying their own solutions
Identify barriers to change and help patients overcome those barriers by identifying their own solutions
A Model for Successful Interventions
A Model for Successful Interventions
Keller VF, White KM. J Clin Outcomes Manage. 1997;4:33-36.; Miller WR, Rollnick S. Motivational interviewing. New York NY: Guilford Press; 1991.
Co
nv
icti
on
(Ben
efits
)C
onvi
nced
Am
biva
lent
0
10
Confidence
Powerless (Barriers) Unwavering10
Pre-contemplation
Contemplation
Preparation Empowered
Skepticism
Lack of knowledge
Cynicism
Frustration
Success
Action
PattyPatty
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
Non-pharmacologic therapies are an important first-line treatment for patients with FMCompliance to lifestyle interventions can be increased by assessing and intervening with motivational interviewing techniquesThe use of multidisciplinary resources can improve outcomes and facilitate time-efficient treatment
Menu
ObjectivesObjectives
Following this module, participants will be able to: Link the medications useful in treatment of fibromyalgia (FM)Match medication properties and side effects with therapeutic targets for patients with FMArticulate safety issues with medications commonly used to treat FM
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. She presented with a typical symptom complex: generalized pain, fatigue, non-restorative broken sleep and mental fogging. You asked her after the first visit to review medication options with a pharmacist who works as part of your interdisciplinary team.
ExerciseComplete the worksheet with your partner
ExerciseComplete the worksheet with your partner
For each class of medication, indicate what is the effect of each symptom, using -, +, ++ or +++, and describe the most common side effects.
*Medication with official indication in fibromyalgia
Class Medications Overall FM
Pain Fatigue Sleep Depression/ anxiety
Most common side effects seen in patients, based on your experience
Antiepilepticanalgesics
Pregabalin*
Gabapentin
Atypical antidepressants Bupropion
Atypical antipsychotics
Benzodiazepines
Cannabinoids
Dopamine agonist Pramipexole
Dopamine NE Modafinil
Muscle relaxant (NE) Cyclobenzaprine
NSAIDs
Opioids
Opioid agonist SNRI Tramadol
Psycho-stimulants Dextroamphetamine, methylphenidate
SNRI Duloxetine*Venlafaxine
SSRI Sertraline
TCA Amitriptyline(desipramine, doxepin, nortriptyline)
Zopiclone
Video 1Video 1
Video de-briefVideo de-brief
Medical Management of FM: Considerations
Medical Management of FM: Considerations
Don’t set unrealistic goals; target functional improvementImportant to manage patient’s expectationsKeep the patient involved in treatment decisionsBalance efficacy with side effectsAvoid rapid dose escalation: start low, go slow!
Medical Management of FM: Considerations (cont’d)
Medical Management of FM: Considerations (cont’d)
Use opioids with caution; keep doses low
Refer to the new Canadian practice guideline on use of chronic opioid therapy for non-cancer pain
Always augment with non-medical therapy
Polypharmacy may be necessary, but keep doses low and be mindful of side effects and function
PolypharmacyPolypharmacy
Often necessary for symptom control
May exacerbate or cause some of the target symptoms of FM (cognitive impairment, sleep disturbance, fatigue)
Be aware of drug interactions (e.g., serotonin syndrome)
Best Evidence: Medication Options in FM
Best Evidence: Medication Options in FM
Medication Mechanism of Action
Efficacy in Overall FM Management
Effect on Major Symptoms
Off/On-Label Indication
Amitriptyline(desipramine, doxepin, nortriptyline)
TCA(NE > 5HT)
+ Pain, sleep, anxiety(poor long term)
Off
Duloxetine SNRI +++ Pain, depression, anxiety
On
Gabapentin 2 binding: ↓neuronal excitation
++ Pain, sleep, anxiety
Off
Pregabalin 2 binding: ↓neuronal excitation
+++ Pain, sleep, anxiety
On
Tramadol Opioid agonistSNRI
++ Pain Off
GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant
(alphabetical order)(alphabetical order)
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
Some Evidence: Medication Options in FM
Some Evidence: Medication Options in FM
Medication Mechanism of Action
Efficacy in Overall FM Management
Effect on Major Symptoms
Off/on-Label Indication
Comments
Atypical antipsychotics
Dopamine ± Sleep Off Open label study
Cannabinoids CB 1 receptor agonist
+ Sleep Off Lack of effectiveness in FM pain
Cyclobenza-prine
Muscle relaxant (NE)
+ Pain, sleep(poor long term)
Off
Pramipexole Dopamine agonist
+ Pain, fatigue Off Limited population studied
Sertraline SSRI ± Pain, depression
Off Compared versus physical therapy
Venlafaxine SNRI > SSRI + Pain, depression, anxiety
Off Limited FM study
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacySSRI, selective serotonin reuptake inhibitor
(alphabetical order)(alphabetical order)
No Evidence: Medication Options in FM
No Evidence: Medication Options in FM
Medication Mechanism of Action
Rationale for Use
Concern for Use
Benzodiazepines GABA increase Anxiety AddictionSide effects
NSAIDs Prostaglandin inhibition
Analgesia NSAID-related side effects
Opioids Opioid receptor agonists
Analgesia AddictionSide effects
Stimulants(dextroamphetamine, methylphenidate)
NEDopamine
Fatigue DiversionAbuse
Zopiclone GABA Sleep
NSAID, non-steroidal anti-inflammatory drug
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy
(alphabetical order)(alphabetical order)
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
Establish realistic treatment goals
Important to manage patient expectations
Chose medications that target the most troublesome symptoms
Start low, go slow – reassure
Use polypharmacy with care
Opioids are controversial
Menu
ObjectivesObjectives
Following this module, participants will be able to: Differentiate the concepts of functional remission versus full symptom remissionEstablish realistic therapeutic goals with patientsUse interdisciplinary team resources to manage patients with fibromyalgia (FM)
Case StudyCase Study
Patty is a 32-year-old patient in your practice who was diagnosed with FM that appeared to start after she slipped on some ice. After communicating the diagnosis to her, you referred her to a local FM lifestyle program. She was also started on a medication targeting sleep restoration, her most debilitating symptom at presentation. She presents for a follow-up visit.
Video 1Video 1
QuestionsQuestions
1. How do you monitor the effectiveness of treatments?
2. What is the realistic endpoint of therapy for FM? Is full remission of symptoms a reasonable goal?
3. How do you explain or negotiate therapeutic goals to patients?
4. How could you use an interdisciplinary team (your own team or resources in your community) to manage your patients with FM?
Take the time to answer each of the questions
Monitoring TreatmentMonitoring Treatment
Currently, there is no currently validated acceptable tool for assessing response to treatment Consider evaluation of patients with FM in these dimensions:
Pain FatigueSleepFunctionality (physical and psychological)Mood
Functional versus Symptom Remission Functional versus Symptom Remission
Symptomatic remission is resolution of all symptoms associated with the condition
Functional remission is improvement of symptoms to the point where patients can maximize function (vocational, interpersonal, social)
Although most patients with FM will not attain full symptom remission in the short term, the natural history of FM is more positive
Fate of Patients with FMFate of Patients with FM
Reassure patients that FM is not progressive and that symptoms remain stable over time1
50% were moderately to greatly improved (3 year follow-up)2
• The baseline predictors for a favorable outcome: younger age and less sleep disturbance2
Successful management requires an upbeat, optimistic approach and EARLY initiation of effective, individualized therapy
1. Kennedy et al. Arthritis Rheum. 1996;39:682-685.2. Fitzcharles et al. J Rheumatol. 2003;30:154-159.
Strategy for ManagementStrategy for Management
Explain the long-term nature of FMReassure the patient that it is not life-threatening Choose therapies that target the most disabling symptom(s)Emphasize functional improvements Balance medication side effects with improvement in function
Medications Options for FM (1) Medications Options for FM (1)
Medication Mechanism of Action
Efficacy in Overall FM Management
Effect on major symptoms
Off/on-Label Indication
Comments
Amitriptyline(desipramine, nortriptyline, doxepin)
TCA(NE > 5HT)
+ Pain, sleep, anxiety
Off FM dose < usual antidepressant dosePoor long term
Cannabinoids CB 1 receptor agonist
+ Sleep Off Lack of effectiveness in FM pain
Cyclobenzaprine Muscle relaxant (NE)
+ Pain, sleep Off Poor long term
Duloxetine SNRI +++ Pain, depression, anxiety
On
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacyNE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant
(alphabetical order)(alphabetical order)
Medications Options For FM (2) Medications Options For FM (2)
Medication Mechanism of Action
Efficacy in Overall FM Management
Effect on major symptoms
Off/on-Label Indication
Comments
Gabapentin 2 binding: ↓neuronal excitation
++ Pain, sleep, anxiety
Off
Modafinil DopamineNE
+ Fatigue Off Open label small study
Pramipexole Dopamine agonist + Pain, fatigue Off Limited population studied
Pregabalin 2 binding: ↓neuronal excitation
+++ Pain, sleep, anxiety
On
Sertraline SSRI ++ Pain, depression Off Compared versus physical therapy
Tramadol Opioid agonistSNRI
++ Pain Off
Venlafaxine SNRI > SSRI + Pain, depression, anxiety
Off Limited FM study
+++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacySSRI, selective serotonin reuptake inhibitor
(alphabetical order)(alphabetical order)
Video 2Video 2
Video de-briefVideo de-brief
SummarySummary
It is rare that treatment will result in full symptom remissionFocus for therapy is to increase the level of function, accepting some degree of residual symptomsEducate patients around realistic treatment goalsWhere possible, quantify symptoms and level of functionAn interdisciplinary team can assist in education, establishing and reinforcing treatment goalsFor pharmacologic treatment: start low, go slow!
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