Rhumatology Exam 1 - RA, PsA, Lupus, Bjorn's dx, Fibromyalgia

fibromyalgia stx’s include

-widespread pain

-specific trigger points

-poor sleep, feel tired

-20-50 y/o

what are associated stx’s of fibromyalgia?

TIME PS H RNR or FIBRO (Fatigue, Insomnia, Blues, Rigidity, Ow)

-Temporomandibular joint stx’s

-IBS

-Morning stiffness

-Exercise intolerance (musc. decond.)

-Psyc (anxiety, depression)

-Sicca stx’s (Sjogren’s; dry mouth and dry eyes)

-H/a

-RLS

-Non-cardiac chest pain

-Raynaud’s

fibromyalgia overlaps with what disease states?

-chronic fatigue syndrome

-IBS

-chronic pelvic pain syndrome/primary dysmenorrhea

-migraine/tension HA

-PTSD

-RLS

-mood anxiety dx’s

-inflammatory disorders: RA, SLE

Describe how HPA Axis dysfxn relates to fibromyalgia with the dec. in 3 hormones

• dec. in growth hormone → dec. tissue repair → dec. O2, Mg, ATP, PO4 → dec. fuel for body (eg dec. Mg = musc. aches)

• DA → dec. limbic fxn → dec. cortisol → dec. body repair

• 5-HT → dec. sleep, inc. pain sensitivity → dec. cortisol → dec. body repair

peripheral mech. of fibromyalgia is via activation of what and via what kind of mito. damage?

-activation of chronic sympathetic → delta sleep disruption → musc. blood flow microconstrictions ,elevated IL-6, TNF, elevated substance P

-mito. damage from toxins → preoxidative rxns = inc. lactic acid

What are the 3 fibromyalgia diagnostic criteria?

1. widespread pain index (WPI) >/ 7 and stx severity (SS) score >/5 OR WPI 3-6 and SS >/9

2. Symptoms present at a similar lvl for < 3 mo.’s

3. pt does not have disorder that would explain pain

What are the updated ACTTION-APS Pain Taxonomy 3 diag. criteria?

1. multisite pain = 6 or more pain sites out of 9

2. moderate to severe sleep problem OR fatigue

3. multistate pain + fatigue sleep problems present for > 3 mo’s

ANS: C

There is NO specific lab tests used for diagnosis

Tx approach to fibromyalgia

no cure, thus:

• pain management → pharma agents

  • (1st line: TCA amitryptyline 10-50mg/daily [AE’s: sedation, constipation, wt gain] [take 1 hr before bed]

  • SSRI: citalopram (2nd line), fluoxetine 20-80mg PO hs (dec. in fibro-fog, sleep and fatigue)

  • SNRI: duloxetine (Cymbarfa) [FDA approved for FM] [good for OA too] : dec. pain, dry mouth, nausea, constipation

  • NSRI: Milnacipran (Savella) [FDA approved for FM] (AE: insomnia)

  • CCB’s [co-morbid periph. neruopathy, h/a’s]:

    • Pregabalin (Lyrica): [approved drug for FM in US] (pregabalin > gabapentin)

    • Gabapentin

  • musc. relaxant: Cyclobenzaprine (Flexeril): dec. pain and inc. delta sleep [AE’s: EXTREME drowsiness]

  • DA Agonists [w/ co-morbid RLS]:

    • pramipexole (Mirapex)

    • Ropinirole (Requip)

  • low dose naltrexone

  • if pts fail:

    • venlafaxine (Effexor)

    • Buproprion (Wellbutrin) [smoking cessation]

• sleep management → education on good sleep hygiene, aerobic exercise (water aerobics)

• psychological support → counseling, support groups, CBT

• complementary options → massage, acupuncture, biofeedback, myofascial release

Treatment guidelines

APS (American Pain Society) 2004

EULAR (European League Against Rheumatism) 2007

What pharma Tx’s to avoid in Fibromyalgia?

• NSAIDs and CS’s: ineffective in FM

• opioids: worsen FM stx’s (AVOID)

• tramadol (an cause serotonin syndrome

• lidocaine transdermal patches (not effective)

alternative meds for FM

• Melatonin

• Magnesium = FM dec. Mg lvls (pulls water into gut → diarrhea)

• capsaicin (applied multiple times per day)

• medical cannabis

how to choose pharma Tx for FM based on other co-morbidities?

A, C, D

A.

milnacipran = can cause insomnia

B (bc FDA approved & periph. neuropathy 2ndary to diabetes)