Fibromyalgia -Lecture 4 - Dr. Scopelliti

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VASUpharm14
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Fibromyalgia -Lecture 4 - Dr. Scopelliti
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2013-04-08 18:18:00
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M/S - FM Understand the proposed pathophysiological mechanisms of FM  Identify the multiple symptoms and comorbidities associated with FM  Discuss the diagnosis of FM using the American College of Rheumatology Criteria for Classification of Fibromyalgia and Measurement of Symptom Severity  Evaluate the role of nonpharmacological and pharmacological treatment options for FM  Develop a treatment plan for FM given a patient case
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  1. Fibromyalgia (FM) definition
    multi-symptom condition with chronic widespread pain
  2. Onset age FM
    20-55 years (increases with age)
  3. FM gender prevalence
    more common in females (F for Female) 9:1
  4. 4 types of pathophysiology for FM
    • 1. dysregulation of pain pathways
    • 2. neuroendocrine abnormalities
    • 3. autonomic nervous system abnormalities
    • 4. environmental factors
  5. key players of pain pathway (2)
    • NMDA/AMPA activation - substance P (bind to NK-1) and glutamate
    • Anti-nociceptive - GABA, serotonin, norepinephrine
  6. dysregulation of pain pathway: deficiency
    • serotonin - regulates sleep, pain control, concentration and memory
    • norepinephrine - pain modulation
  7. dysregulation of pain pathway: enhanced
    release of substance P
  8. neuroendocrine abnormalities
    • HPA axis is altered
    • - inability to suppress cortisol
    • -normally controls reactions to stress and other functions (circadian rhythm, digestion, body temperature).
  9. autonomic nervous system: components (2)
    • growth hormone (GH)
    • insulin-like growth factors-1 (IGF-1)
  10. process of autonomic nervous system normal and FM
    • normal: slow wave sleep (SWS) produces GH --> GH produces IGF-1 --> repair of muscle microtrauma
    • FM: decreased
  11. environmental factors FM
    • physical stressors
    • psychosocial stressors
  12. genetic influences for FM
    • first degree relative 8x
    • affects the transport and metabolism of serotonin and norEPI
  13. Increased pain sensitivity: decrease of
    • 1. serotonin
    • 2. norepinephrine
  14. Increased pain sensitivity: increase of
    1. substance P
  15. Implications of FM due to autonomic nervous system dysfunction
    • 1. impaired exercise tolerance
    • 2. HYPER arousal (affects sleep)
  16. Most associated symptom with FM
    • 1. Muscular pain (makes sense for this class)
    • 2. Fatigue
    • 3. sleep abnormalities
  17. pain characteristics of FM (3)
    • 1. chronic widespread pain
    • ≥3 months, ALL 4 QUADRANTS, not localized in joints (arthritis)
    • 2. pain waxes and wanes
    • 3. tenderness
  18. pain characteristics of FM: allodynia
    pain from something that shouldn't hurt
  19. pain characteristics of FM: HYPER algesia
    super sensitive
  20. diagnosis
    • difficult and delayed
    • and impacts costs and function of life
    • 4 quadrants 
    • 3 months or longer
    • 11/18 tender points
  21. disadvantages of American College of Rheumatology (ACR) Criteria for Classification of FM (4)
    • 1. focuses on pain and disregards other sx
    • 2. tenderness is subjective
    • 3. depends on examiner's strength of palpitation
    • 4. many believe 11/18 is arbitrary
  22. t/f treatment is often trial and error
    true
  23. Strong evidence medications for FM (4)
    • 1. TCA (amitriptyline)
    • 2. Cyclobenzaprine
    • 3. SNRI's (duloxetine, milnacipran, venlafaxine)
    • 4. Gabapentin, pregabalin
  24. Modest evidence medications for FM (3)
    • 1. Dopamine agonist
    • 2. SSRI's
    • 3. Tramadol
  25. No evidence medications for FM (4)
    • 1. opioids
    • 2. NSAIDs
    • 3. Benzos
    • 4. Hypnotics
  26. FDA approved medications for FM (3)
    • 1. Pregabalin (Lyrica)
    • 2. duloxetine (Cymbalta)
    • 3. Milnacipran (Savella)
  27. MOA: analogue GABA reduce Ca2+ = DECREASE release glutamate, substance P
    hint: FDA approved
    pregabalin (Lyrica)
  28. dose: 75 mg PO twice daily --> 150 mg PO bid (within 1 week) --> max 450 mg/day
    hint: FDA approved
    pregabalin (Lyrica)
  29. SE of Lyrica
    dose-related drowsiness and dizziness
  30. MOA: SNRI - inhibits reuptake of both serotonin and norepinephrine (2)
    hint: FDA approved
    • duloxetine (Cymbalta)
    • milnacipram (Savella)
  31. dose: 30 mg PO QD 1 week --> 60 mg PO QD --> max 60 mg/day
    hint: FDA approved
    duloxetine (Cymbalta)
  32. Amitriptyline: benefits and disadvantages
    • benefits: pain relief, improved sleep, decreased AM stiffness
    • disadvantages: intolerance, long term effectiveness questionable
    • not FDA approved
  33. cyclobenzaprine information
    • muscle relaxant
    • mixes results in literature
    • short-term
    • pain relief and improved sleep
    • not FDA approved
  34. tramadol information
    • mu-opioid receptor agonist
    • serotonin and norepinephrine reuptake inhibitor
    • pain relief of FM
    • not FDA approved
  35. SSRI's information
    • relief depressive symptoms
    • lack of efficacy for pain - use TCA's and SNRI's instead
  36. symptom management: depression (2)
    • 1. SNRI - duloxetine, milnacipram, others
    • 2. TCA's
  37. symptom management: insomnia (4)
    • 1. health sleep regimen
    • 2. non-benzo hypnotics
    • 3. sedating antidepressants
    • 4. cyclobenzaprine
  38. nonpharm management FM (4)
    • 1. education
    • 2. exercise
    • 3. CBT
    • 4. complementary therapy

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