Dr Abhishek - Nottingham University Hospitals NHS Trust

Managing fibromyalgia – top tips
and getting to grips!
Dr A Abhishek
Clinical Associate Professor
University of Nottingham
Honorary Consultant Rheumatologist
Nottingham University Hospitals NHS Trust
Overview
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Cases – yours and mine
Understanding the disease
Symptoms and signs
Management
– Non-pharmacological
• Education
• Therapy
– Pharmacological
Cases – your
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Story
Findings
Tests
Progress
Cases – mine
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Story
Findings
Tests
Progress
Epidemiology
Prevalence – 2% in the western world
Females >> Males
Age
Deprivation
Do you believe in fibromyalgia being a true
diseases entity?
Central augmentation
Augmented sensory input
Pathophysiology
serotonin
norepinephrine
dopamine
Autonomic
nervous system
5-HT transporter
COMT gene
acute injury
accidents
chronic ill health
Hypothalamic
pituitary axis
cortosol
IGF 1
growth hormone
Genetic
Physical
stressors
Psychosocial
factors
Sleep disturbance: reduced delta wave sleep
abuse
deprivation
mental health
Pathophysiology
↓ sleep
Strategies aimed at
increasing sleep
improve symptoms
↑ pain
↓ IGF1, GH
↓ sleep
↓ microinjury repair
↑ pain
↑ fatigue
Symptom complex in fibromyalgia
Anxiety
Pain
Psychological
symptoms
Depression
Patient
Somatic
symptoms
Fatigue
Distress
Tiredness
Paresthesiae
Disability
Poor sleep
IBS/GORD
Panic disorder
Poor memory
Dificulty coping
Asthma, cough, migraine
Key symptoms in fibromyalgia
Unrefreshing
Widespread
Back
Limbs
Constant
Pain
T-M joint
Sharp
Insomnia
Sleep
Stabbing
Not activity related
Non-restorative sleep
Poor quality
Look more carefully…
Early life experiences
FMS
Recent
Social
significant events
and family life
Examination
Mimes and investigations
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FBC
U&E, LFTs, calcium, phosphate, TSH
ESR, CRP
Vitamin D
Coeliac screen – anti-TTG antibodies
Immunoglobulin electrophoresis
ANA, CK
Patient’s concerns
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What is wrong with me?
Why have I got it?
Will I get worse - wheelchair?
Is it in my mind ?
Can I be cured?
There is no cure is there ?
Dr Google says .. what do you think?
Patient’s concern …. rarely addressed
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What is wrong with me?
..fibromyalgia
Why have I got it?
…don’t know, I will refer..
Will I get worse - wheelchair?
…may be
Is it in my mind ?
….?....
Can I be cured?
NO
There is no cure is there ?
YES, that’s right
Dr Google says .. what do you think? …..ask the
specialist who you see in hospital
Treatment
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Accept symptoms are real
Diagnose with confidence
Empathise about the condition
Explain about the disease
Educate about the treatment
Non-pharmacologic, pharmacologic treatment
Follow-up
Non pharmacological treatment
• Heated pool treatment +/- exercise
• Individually tailored exercise programmes
including aerobic exercise and strength
training
• Cognitive behavioural therapy
• Other therapies such as relaxation,
rehabilitation, physiotherapy and
psychological support
Pharmacological treatment
• Simple analgesics
• Weak opiates
• Tramadol: do not prescribe potent opioids or
chronic NSAIDs
• Antidepressants: amitriptyline, fluoxetine,
duloxetine, milnaciprane and pirlindole
• Tropisetron, pramipexole and pregabalin
Drugs and the lot
Despite adequate pain relief, these interventions do not
translate into improved quality of life on HAQ or on SF 36
What do you do?
Most patients agree to a
management plan for
symptomatic benefit
GP
Pain
clinic
Hospital
MDT
clinic
Therapy
Getting to grips
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Drug therapy is not mandatory.
Shared decision-making
Augment placebo and reduce nocebo response
Start low, go slow
Monitor for efficacy, tolerability, and safety
Promote long-term drug-free self-management
Any questions
Any questions
Thank you