SANTA MONICA, CALIF. — Effective treatments exist for fibromyalgia syndrome, but many physicians still do a poor job of treating affected patients, Dr. Chad S. Boomershine said at a meeting sponsored by Rheumatology News and Skin Disease Education Foundation.
Could it be that these physicians don't consider fibromyalgia to be a “real” disease, that they perceive affected patients as being too time consuming and unlikely to get better? asked Dr. Boomershine, a rheumatologist at Vanderbilt University in Nashville, Tenn., where he specializes in treating fibromyalgia in collaboration with the Vanderbilt Center for Integrative Health and the Vanderbilt Dayani Center.
About 2%-4% of the U.S. population meets the fibromyalgia classification criteria issued in 1990 by the ACR. The true prevalence is estimated to be about twice as high, and—as prevalence increases with age—fibromyalgia is expected to become more common with the aging of the population.
The ACR classification criteria for fibromyalgia include widespread pain for at least 3 months' duration, and pain at a minimum of 11 of 18 specified tender points when enough pressure to just blanch the examiner's thumbnail is applied. The reported 9:1 ratio of women to men with the condition is incorrect, he said, as women have more tender points and men are more likely to self-medicate rather than to seek medical care.
Fibromyalgia typically involves symptoms other than pain, which Dr. Boomershine teaches using the FIBRO mnemonic (F for fatigue and ‘fibrofog’ [cognitive dysfunction], I for insomnia [nonrestorative sleep], B for blues [depression and anxiety], R for rigidity [muscle and joint stiffness], and O for Ow! [pain and work disability]). Nevertheless, pharmacologic management should start by treating pain because it is the one symptom common to all fibromyalgia patients, he said.
When choosing among the three indicated medications, a physician should individualize therapy based on the associated symptom that is most disabling for the patient, he recommended.
Pain associated with insomnia is best treated with pregabalin (Lyrica), he said. The label states that pregabalin should be given in two divided doses daily beginning with a total of 150 mg/day and increasing to as much as 450 mg/day if needed. In an effort to avoid the typical side effects of dizziness, somnolence, fatigue, and cognitive dysfunction, however, Dr. Boomershine recommends beginning with 25-75 mg once daily at bedtime and titrating up to 150-225 mg at night before adding a morning dose.
Pain with depression and/or anxiety is best managed with duloxetine (Cymbalta) every morning, he said. The label states that the recommended dosage for fibromyalgia is 60 mg/day, but Dr. Boomershine recommends starting with 20-30 mg and increasing to 60 mg only if necessary. Trial data indicate that many patients do well on lower doses, he noted, and higher doses are associated with increased risk for side effects, including nausea, headache, and insomnia.
For pain associated with fatigue or fibrofog, the treatment of choice is milnacipran (Savella), he said. The label for this agent recommends starting at a dose of 12.5 mg once daily and gradually working up to 50 mg twice daily after 1 week and a maximum dosage of 100 mg twice daily if needed. Dr. Boomershine said he recommends a more gradual up-titration and noted that the dose should be increased only if needed because of the patient's symptoms. Milnacipran is available in 12.5-, 25-, 50- and 100-mg tablets, allowing for dosing flexibility.
Physicians with years of experience in successfully managing fibromyalgia are accustomed to using other drugs that lack Food and Drug Administration approval specifically for use in fibromyalgia.
Amitriptyline given as a 25-mg dose at bedtime in combination with fluoxetine (20 mg) in the morning is a “particularly good combination,” said Dr. Boomershine. He noted that the combination has shown good efficacy and likely provides balanced norepinephrine and serotonin reuptake inhibition similar to that provided by duloxetine and milnacipran, but at a much lower cost.
Dr. Boomershine recommends avoiding the use of narcotics, benzodiazepines, or steroids in treating fibromyalgia symptoms.
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