Fibromyalgia: A Multi Disciplinary Approach and Drugs for Treatment

Stuart L. Silverman MD FACP FACR,

Clinical Prof Med Rheum UCLA/Cedars Sinai

These two articles appeared in the syllabus of the FAME 2001 Conference and are used with permission of the conference organizers.

General measures for all patients with fibromyalgia include education as to the nature of the disorder and what to expect from treatment, instruction in stress management, coping skills, development of an individual program for flare management, development of a regular exercise program and a daily stretching program. Aquatic therapy if available may be preferred by many patients to land therapy.

Social support is also needed. Patient support groups in the community may be helpful for some individuals. Patients wit fibromyalgia often state that their friends or family do not believe their diagnosis. Not all physicians may be supportive of patients with a diagnosis of fibromyalgia.

When available, a team approach is suggested for patients with difficult symptoms, fibromyalgia of long duration, cognitive dysfunction, significant anxiety or depression, significant functional loss or narcotic dependency. Our core fibromyalgia team at Cedars Sinai Medical Center, which has been in existence for over 8 years consists of an occupational therapist who also teaches sleep hygiene, a physical therapist, a psychologist trained in cognitive behavioral therapy, EMG/Biofeedback specialist and a rheumatologist.

We also use at times a nutritionist, a complementary medicine physician, social worker, vocational rehab specialist and a neuropsychologist. A physician can create his or her own team, using health care providers in the community who have been educated in the specific needs of the fibromyalgia patient (physical therapy for a patient with FM is often at a slower pace than cardiac rehab).

The Pharmacologic Approach to Fibromyalgia: Using drugs effectively in the treatment of fibromyalgia

Pain, fatigue, sleep disorders, irritable bowel, cognitive dysfunction and associated anxiety and depression are among the symptoms of fibromyalgia that may be responsive to drug therapy.

Peripherally acting analgesics such as COX2, NSAIDs, centrally acting analgesics such as tramadol, antidepressants, anticonvulsants such as gabapentin, and muscle relaxants e.g. tizanidine may help relieve pain. Opioid analgesics may be helpful in a small number of patients but are usually best avoided.

Local barriers may need to be treated with selective trigger point injection. Sleep disorders may respond to improved sleep hygiene, herbal sleep aids, low dose antidepressants, gabapentin, nonbenzodiazepine hypnotics such as zolpidem, or assessed for bacterial overgrowth and given appropriate antibiotic treatment.

Cognitive dysfunction will often respond to improved sleep and treatment of depression. However a few patients may benefit from nimodipine. Depression and anxiety can be managed with antidepressants and anxiolytic therapy. All patients should also be treated with general measures of education, stress management, daily stretching and regular exercise. Other concomitant problems that may respond to appropriate medications include migraine and urethral syndrome.

Since patients with fibromyalgia have multiple symptoms, polypharmacy is common. Low doses are preferred as patients with fibromyalgia may be very sensitive to medication. Medications may lose effectiveness with time. There are potential problems with medications including interactions and side effects. Herbal medications may be helpful in some patients for some symptoms.

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