EP is a twenty-five-year-old African American female who has just moved to town and comes to the clinic for her first visit. She has been diagnosed with fibromyalgia. She reports that her previous primary care physician (PCP) was treating her with opiates only. She has been taking hydrocodone/ibuprofen 7.5 mg/200 mg four times daily but notes that this is not helping her. She is asking you for a refill of this medication and any additional treatment you can advise. On physical exam, she is in moderate distress and reports pain when being touched. Answer the following questions:
- How would you validate the diagnosis of fibromyalgia?
- How would you handle EP’s request for ongoing hydrocodone? Locate any evidence of the efficacy of this treatment for fibromyalgia.
- Assuming that the diagnosis is correct, what would your treatment plan be?
- Would you recommend any nontraditional therapies?
For medications, include dosages and schedules. Include highlights of patient teaching and/or lifestyle alterations. Support your decisions with at least one reference to a published clinical guideline and one peer-reviewed publication.
Expert Solution Preview
Introduction: In this scenario, a patient with fibromyalgia has come for a visit. As a medical professor, I will provide answers to the following questions regarding the validation of the diagnosis of fibromyalgia, handling the request for ongoing hydrocodone, treatment plan, and nontraditional therapies.
1. How would you validate the diagnosis of fibromyalgia?
The diagnosis of fibromyalgia is made based on clinical presentation and history. Tender points are no longer required for diagnosis, instead, widespread pain in all four quadrants of the body lasting for at least three months and other symptoms such as fatigue, non-restorative sleep, and cognitive symptoms should be present. It is important to rule out other conditions that might present with similar symptoms such as rheumatoid arthritis, lupus, and thyroid disorders. Therefore, a thorough physical examination and laboratory investigations including complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), thyroid function tests, and rheumatoid factor should be done.
2. How would you handle EP’s request for ongoing hydrocodone? Locate any evidence of the efficacy of this treatment for fibromyalgia.
Opioids are not recommended as a first-line treatment for fibromyalgia and there is no evidence for their efficacy for this condition. Instead, treatment should be initiated with non-opioid analgesics such as nonsteroidal anti-inflammatory drugs, acetaminophen, and/or tramadol. Antidepressants such as amitriptyline, duloxetine, and milnacipran have been shown to be effective for the treatment of fibromyalgia. In addition, pregabalin, a gabapentinoid, and gabapentin have been FDA-approved for the treatment of fibromyalgia. Therefore, I would explain the potential risks of opioid use and the lack of evidence for its efficacy in fibromyalgia and discuss the alternative treatment options with the patient.
3. Assuming that the diagnosis is correct, what would your treatment plan be?
My treatment plan for fibromyalgia would include a combination of non-opioid analgesics, antidepressants, and/or gabapentinoids. I would start with the lowest effective dose and titrate to symptom relief. Pregabalin 75 mg twice daily can be initiated and increased to a maximum dose of 300 mg/day. Amitriptyline can be initiated at a low dose of 10-25 mg at night and titrated to up to 100 mg/day. Lifestyle modifications such as exercise, stress reduction, and balanced nutrition should also be discussed. I would schedule regular follow-ups to assess the patient’s response to treatment and adjust the medications as needed.
4. Would you recommend any nontraditional therapies?
Some nontraditional therapies with possible benefit include acupuncture, massage therapy, and cognitive behavioral therapy. Tai chi and yoga have also been shown to be beneficial for fibromyalgia. However, it is important to note that there is limited evidence for the efficacy of nontraditional therapies, and they should be used in conjunction with evidence-based treatments. Therefore, I would recommend discussing these options with the patient and referring them to a qualified practitioner if they are interested.
References:
– Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. ACR Clinical Classification Criteria.
– Arnold LM, et al. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc. 2012;87(5):488-496.
– Russell IJ, et al. Efficacy of duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized clinical trials. J Women’s Health. 2009;18(8):1145-1156.
