Derm Exam 2: Yamaki Fibromyalgia/SLE

Fibromyalgia

• "Central Pain Amplification" — the nervous system's volume for pain is “______”

• Diagnosis Criteria

  • Pain areas (>7 of 19 body parts) over past week + severity of fatigue, unrefreshed sleep, cognitive problems

  • Symptoms present at similar level for ≥ 3 months

  • Measured with: ______ + ______

• Non-Pharm Treatment: ______ = very effective

turned up too high, Widespread Pain Index (WPI), Symptom Severity Scale (SSS), Physical Exercise

Fibromyalgia

• FDA APPROVED for Myalgia Treatment

  • ______ – ______

  • ______ – ______

  • ______ – ______

Duloxetine, Cymbalta, Milnacipran, Savella, Pregabalin, Lyrica

______ – ______

• Avoid if CrCl < 30 mL/min (impaired kidney function)

• Same BBW as antidepressants

• Avoid NSAIDs/ASA

• Renal Adjustment: CrCl < 30 → avoid + no Heart Disease (HD)

Duloxetine, Cymbalta

Duloxetine – Cymbalta

• AVOID if CrCl ______ mL/min (______)

• Same ______

• Avoid ______

• Renal Adjustment: CrCl ______ → avoid + no ______

<30, impaired kidney function, BBW as antidepressants, NSAIDs/ASA, <30, Heart disease

______ – ______

• ONLY Indication: Fibromyalgia

• Dosing: Renal adjustment required

• Warning + ADRs: No if dialysis, Same BBW as SSRIs/SNRIs, Avoid NSAIDs/ASA

• Renal Adjustment: CrCl < 30 → Required Adjustment + No in HD

Milnacipran, Savella

Milnacipran – Savella

• ______ Indication: ______

• Dosing: ______ required

• Warning + ADRs: No if ______, Same ______, Avoid ______

• Renal Adjustment: CrCl ______ → ______ + No in ______

Only, fibromyalgia, renal adjustment, dialysis, BBW as SSRIs/SNRIs, NSAIDs/ASA, <30, Required adjustment, heart disease

______ – ______

• Dosing: Must be renally adjusted

• Renal Adjustment: CrCl < 60 → Required Adjustment

Pregabalin, Lyrica

Pregabalin – Lyrica

• Dosing: ______

• Renal Adjustment: CrCl ______ → ______

Must be renally adjusted, <60, required adjustment

Fibromyalgia

• Dampens the ______ that ______ by targeting ______ channels.

• The ______; duloxetine and milnacipran, ______ pain sensory ______ pathways by raising serotonin and norepinephrine levels.

release of excitatory NTs, signal pain, voltage-gated calcium, SNRIs, boost, inhibitory

Fibromyalgia

• Off-Label Use

  • Cyclobenzaprine – ______ → ______

  • Gabapentin

• MEDICATIONS TO AVOID

  • ______

  • ______

  • ______

Tonmya, IS labeling, Opioid Narcotics, BZDs and Z-Drugs, APAP and NSAIDs

Pathophysiology of SLE

• Defective clearance of apoptotic cells → ______ (DNA, RNA)

• Innate Immune Activation

• T-Cell Activation

• B-Cell Activation + Survival

• Immune Complex Formation

• Inflammation + Organ Damage

exposure of nuclear antigens

Systemic Lupus Erythematosus (SLE)

• Specific Labs to Support Diagnosis IF Abnormal

  • ______

    • If ANA is positive → ______

Anti-Nuclear Ab (ANA), Anti-dsDNA Abs

Systemic Lupus Erythematosus (SLE)

• Treatments

  • ______

  • Belimumab

  • Anifrolumab

Hydroxychloroquine (HCQ)

______

• Rare (but serious) SEs: retinal toxicity (retinopathy) w/long-term use of doses greater than 5mg/kg → pt should have  a complete eye exam done at baseline (every 5 years)

• Mild (skin, joint involvement): 200-400 mg daily in divided doses

• Moderate (musculoskeletal, hematologic): 200-400 mg daily in divided doses

Hydroxychloroquine (HCQ)

Hydroxychloroquine (HCQ)

• Rare (but serious) SEs: ______ (______) w/long-term use of doses greater than 5mg/kg → pt should have a complete ______ done at baseline (every ______)

• Mild (skin, joint involvement): ______ in divided doses

• Moderate (musculoskeletal, hematologic): ______ in divided doses

retinal toxicity, retinopathy, eye exam, 5 years, 200-400 mg QD, 200-400 mg QD

Belimumab

• Good if patient has more ______ (B-cells) ______

• May be preferred with ______.

autoimmune, antibody driven, lupus nephritis

______

• Good if patient has more autoimmune (B-cells) antibody driven

• May be preferred with lupus nephritis.

Belimumab

______

• Blocks IFN signaling

• Good for more inflammation INF driven lupus

Anfrolumab

Anifrolumab

• ______

• Good for more ______

Blocks IFN signaling, inflammation INF-driven lupus

KNOW IMAGE

What are the four diagnostic criteria that LM must meet to be diagnosed with fibromyalgia (Pathway 1)?

• WPI ≥ ______

• SSS ≥ ______

• Symptoms present ≥______ at a similar level

• No other disorder explains the symptoms

7, 5, 3 months

Is there a laboratory test that confirms fibromyalgia?

No, it’s a symptom-based diagnosis

Name LM's comorbidities or risk factors that are consistent with fibromyalgia.

• ______

• ______ (middle adulthood)

• ______

• ______

• ______ (______)

• ______ pain

• ______

• Sedentary ______

Female, Age 42, IBS, GAD, Family Hx, sister with fibromyalgia, chronic lower back, non-restorative sleep, lifestyle/stress

What are the three FDA-approved medications for fibromyalgia?

Duloxetine (Cymbalta), Milnacipran (Savella), and Pregabalin (Lyrica)

What drug class is pregabalin?

anticonvulsant/analgesic

Which fibromyalgia medication is a Schedule V controlled substance?

Pregabalin (Lyrica)

Which FDA-approved fibromyalgia medication has fibromyalgia as its only FDA-approved indication?

Milnacipran (Savella)

Why is starting duloxetine concerning in LM?

serotonin syndrome

What is the preferred management of LM's sertraline before starting duloxetine?

Carefully taper/discontinue sertraline and transition to duloxetine

Why should ibuprofen generally be avoided with duloxetine?

Increased bleeding risk

How should duloxetine be started for fibromyalgia?

30 mg QD for 1 week, then increase to 60 mg QD

What is the maximum recommended dose of duloxetine for fibromyalgia?

60 mg/day

Can duloxetine be taken with food?

Yes, with or without food

Why should patients avoid alcohol while taking duloxetine?

Increased risk of hepatotoxicity

Name the common SEs of duloxetine.

• ______

• ______

• ______

• ______

• ______

• ______

Nausea, Dizziness, Headache, Insomnia, Constipation, Dry mouth

What Black Box Warning does duloxetine carry?

Increased risk of suicidal thoughts and behaviors (<25 y/o)

At what CrCl should duloxetine be avoided?

<30 mL/min

At what CrCl does pregabalin require renal dose adjustment?

equal or <60 mL/min

Does milnacipran require renal dose adjustment?

Yes, in moderate-to-severe renal impairment

What is the most effective non-drug treatment for fibromyalgia?

Aerobic exercise

Name the evidence-based non-pharmacologic treatments for fibromyalgia.

• ______

• ______

• Mindfulness/MBSR

• Sleep hygiene

• Tai Chi

• Yoga

• Stress management

Aerobic exercise, CBT

With LM's CrCl of 78 mL/min, can all three FDA-approved medications be used at standard doses?

Yes

Why is CBT recommended for LM?

• It helps modify ______ affecting ______ and ______

thoughts and behaviors, pain perception, anxiety

Why is sleep hygiene especially important for LM?

• She has ______ and improving sleep can reduce fibromyalgia Sxs

non-restorative sleep