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Fibromyalgia: A Primary Care Approach

Fibromyalgia: A Primary Care Approach

Veronica Hackethal, MD

Jun 26, 2018

Fibromyalgia

Patient resources include the University of Michigan FibroGuide and the Arthritis Foundation patient information page.

Fibromyalgia is a controversial condition. There is no clear cause, no definitive diagnostic tests, and only a modest response to therapy. Patients often have difficulty convincing others that their symptoms are real.

To help you deal with the challenges of caring for patients with fibromyalgia, I offer a straightforward approach.

One in 20 patients in primary care may have fibromyalgia,1 and women have twice the risk of men.2 The average delay in diagnosis is 2 years. About 46% of primary care physicians report uncertainty with the diagnosis of fibromyalgia.3

Symptoms include widespread pain, joint stiffness, nonrestorative sleep, fatigue, mood disturbances, altered cognition (“fibrofog”), and headaches. Fatigue has been reported as the worst symptom.

Fibromyalgia has many comorbid conditions, including temporomandibular joint and muscle (TMJ) disorders, irritable bowel syndrome (IBS), interstitial cystitis, anxiety/depression, vulvodynia, chronic back pain, endometriosis, noncardiac chest pain, posttraumatic stress disorder (PTSD), and restless legs syndrome.

In 2010, the American College of Rheumatology (ACR) released preliminary diagnostic criteria for fibromyalgia.4 Note that the tender point examination is no longer required but may be useful.

The ACR has not yet endorsed the 2016 revised criteria.5

Other diagnostic considerations include the results of a tender point examination: pain at 11 of 18 sites (left and right side, above and below waist). The examination has a sensitivity of 88% and a specificity of 81%.

No standard laboratory tests are required. The minimum tests recommended are creatinine, calcium, aspartate aminotransferase (AST), alanine aminotransferase (ALT), thyroid-stimulating hormone (TSH), complete blood cell (CBC) count, urinalysis, and basic metabolic panel (BMP). The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), antinuclear antibody (ANA), and other serologic tests are poor screening tools.

The American Academy of Family Physicians (AAFP) recommends evaluation for comorbid functional pain syndromes, sleep disorders, and mood disorders.6

Management follows an organized team approach in the primary care medical home model. The most recent management guidelines were released by the European League Against Rheumatism (EULAR) in 2016.7

The cornerstone of care consists of education, cognitive behavioral therapy (CBT), sleep hygiene, regular aerobic exercise, and management of comorbidities. The most consistent evidence is for the efficacy of exercise. No consistent evidence supports the efficacy of any complementary and alternative medicine (CAM) modality.

Pharmacotherapy for fibromyalgia has variable efficacy. Three medications have been approved by the FDA for fibromyalgia: duloxetine, milnacipran, and pregabalin. Tricyclic antidepressants (TCAs) such as amitriptyline, serotonin-norepinephrine reuptake inhibitors (SNRIs), and cyclobenzaprine have the strongest evidence for benefit. Others with some efficacy are gabapentin and tramadol; however, the use of tramadol to treat fibromyalgia is controversial. Nonsteroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), opioids, antiepileptics, and corticosteroids are generally ineffective for fibromyalgia.

Note that patients discontinue more than 50% of prescriptions because of inefficacy or adverse effects.1

Among the most common indications for referral are concern for systemic rheumatic disease, suspected psychiatric condition other than anxiety/depression, suicidal ideation, narcotic-dependent pain, suspected statin myalgia in known cardiovascular disease (CVD), administrative disability claim, inability to do limited exercise, and concern for chronic infection.

Patient resources include the University of Michigan FibroGuide and the Arthritis Foundation patient information page.

Fibromyalgia is a controversial condition. There is no clear cause, no definitive diagnostic tests, and only a modest response to therapy. Patients often have difficulty convincing others that their symptoms are real.

To help you deal with the challenges of caring for patients with fibromyalgia, I offer a straightforward approach.

References

1. Higgs JB. Fibromyalgia in primary care. Prim Care Clin Office Pract. 2018;45:325-341.

2. CDC. Fibromyalgia. cdc.gov/arthritis/basics/fi... Accessed June 19, 2018.

3. Hadker N, Suchita G, Chandran AB, et al. Primary care physicians’ perceptions of the challenges and barriers in the timely diagnosis, treatment and management of fibromyalgia. Pain Res Manag. 2011;16:440-444.

4. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62:600-610.

5. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46:319-329.

6. Kodner C. Common questions about the diagnosis and management of fibromyalgia. Am Fam Physician. 2015;91:472-478.

7. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76:318-328.

Better to review the post via the two URLs below:

Source: rheumatologynetwork.com/fib...

lupus-support.org/topic/300...

3 Replies
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I actually have real issues with this review and the biggest of which is this:

"The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), antinuclear antibody (ANA), and other serologic tests are poor screening tools".

For what I ask? Fibro or the very conditions they are meant to look for?

Having been involved with a Fibro charity and having run a support group for over 5 years for people with Fibro, I can say that most people find they have an underlying condition which is not properly diagnosed. They have changed the diagnostic criteria a number of times but because there are not any "tests" that clearly diagnose this condition, it should really be one that is given after all others have been excluded given the many cross over symptoms it has with other conditions. In my view the above tests most definitely should be done, not to look for Fibro but to rule out other conditions that could quite easily be missed and could seriously effect the patients health if misdiagnosed - as in my case.

Personally I think too many doctors are too quick to point the finger in this direction because its a cheap option, no expensive tests to run and a quick script of a medication which will probably give them some sort of bonus, because its being pushed by the medical reps from the pharmaceutical company thats been hammering on his door all week for an appointment! Perhaps the reason for the high failure rate and inefficiency of medication is because its not the correct medication in the first place! Also its interesting to note the common indictions for referral, which to me point to other conditions not related to Fibro, which is for the most part a chronic pain syndrome causing central sensitivity syndrome. Most of the conditions mentioned above are things that should be investigated in their own right, which explains very well why people with just about anything now can get clumped together under the Fibro umbrella!

Nothing much has changed in the past 10 years!

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It's well known that FM is frequently the "catch all" diagnosis when doctors are unable to diagnose someone's condition.

It is also common for FM to occur within other autoimmune conditions, for example, SLE or APS.

One of the problems I have is with CBT ie Cognitive Behaviour Therapy, which is the NHS preferred therapy, mostly because a high ranking British economist raved about CBT; and because it's cheap. However, CBT is advertised in a way that I think unethical. For example, it is frequently cited as "evidenced based" but this is not explained that this often means that other therapies have not produced the kind of study that CBT promotes. That is, the absence of studies doesn't mean that CBT is best! Psychoanalytic psychotherapy/psychoanalysis is frequently not only down played, but there is an emotional bias against it! However, long term studies (ie more than 6 months or 2 years) post therapy, show that those patients treated with psychoanalytic psychotherapy, not only do not deteriorate in terms of say, depression (and why would someone not feel depressed or anxious at some point, if struggling with chronic pain and disease), bur continue to improve over time.

There should be specialists in FM but they are few and far between. More concern seems to be on the doctors, than listening to the patient!

Thanks for your input!

Reply

Yes I think it’s not because they are unable to diagnose someone's condition ( in most cases) but more that they don’t bother to try.

As for CBT, I also agree, there is an assumption, much as there was with those suffering from ME that much of what people were suffering from was “ all in their head”. Whilst many were suffering from a reactive depression, and as you say who wouldn’t after months or years of suffering pain, not being believed and getting no treatment, that may be helped to a degree, any underlying condition is not going to be controlled in the long run.

Therefore like many things in the health service it’s a false economy. Additionally and unfortunately, once “labelled” it isn’t easy to gain the respect needed in order to get to the bottom of what is really going on so a vicious circle.

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