0521779407-07 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:10
570 Fibromyalgia➣Emphasize that pain is occurring because of disturbance in how
nervous system senses pain (ie, “volume control is turned up too
high on nervous system”), not because of damage or inflamma-
tion in peripheral structures
➣Emphasize that fibromyalgia cannot be cured (like most chronic
illnesses)
➣Pts do best if they take an active approach to mgt, rather than
adopting “victim” mentality, helplessness
■Explore whether there are stressors that are worsening symptoms
■Refer patients to high-quality sources of information (eg, Arthritis
Foundation, http://www.fms-cfs.org)General Measures
■Most pts require multimodal therapy consisting of symptom-based
pharmacologic therapy, exercise, structured education or cognitive-
behavioral therapy
■For all therapy (drugs, exercise), “start low, go slow”specific therapy
■Pharmacologic
➣If pain is only symptom, non-narcotic analgesic (eg, tramadol or
NSAID) may be effective
➣For pts w/ other symptoms (eg, insomnia, fatigue, etc) initiate a
tricyclic agent (eg, amitriptyline, beginning at 10 mg 2–3 hours
prior to bedtime). Increase by 10 mg every 1–2 weeks to maxi-
mum of 70 mg amitriptyline. Morning sedation, weight gain, dry
mouth, constipation are most common side effects. For pts intol-
erant of tricyclics or where there is incomplete response, SSRIs
(fluoxetine or citalopram) may be added.
➣Other possibilities are trazodone or zolpidem for sleep, gaba-
pentin for pain, bupropion for fatigue
■Exercise
➣Low-impact, aerobic-type exercise is of greatest benefit
➣May be better tolerated once pharmacotherapy has begun
Start w/ 5–10 minutes 3×/week, increasing to 20–30 minutes
5 ×or more per week
➣Strength training may be better late in treatment course
■Cognitive-behavioral therapy (CBT)
➣Teaches pts techniques they can use to manage their symptoms
better
➣Most accessible are Arthritis Foundation self-help courses