Fibromyalgia

Long Term Care Columnist / Guide · Jan 21, 2004

Dave, I wish YOU were my primary care provider sometimes......my doctor doesn't even BELIEVE in fibromyalgia! As a result, I've never been diagnosed properly.......I actually had a patient inadvertently "dx" it several years ago. She was showing me, on me, where her trigger points were......and she almost had to scrape me off the ceiling!! Since then I've read several books about it, and I know darned well I have it, although not to the extent where CFS is involved. I have trigger points pretty much all over the place, and this winter I've developed two more (bilateral shoulders). Generally, I just use Tylenol and Naprosyn or Motrin when it's really bad, and my husband massages me once or twice a week. I also use a heating pad on the places where I hurt the most. This regimen doesn't completely take away the pain, but at least I can live with it most of the time, and it bothers me a lot less in the warm months (not coincidentally, that's when I have NO depressive sx).

I occasionally take Soma (my sister's prescription) or borrow some Flexeril from a friend at work, and that, along with my nightly Ativan, does help me get a good quality night's sleep; I just can't get these from my doc because he thinks they're "bad drugs" and won't prescribe them.

Do you have any ideas for me? I can live with the situation as it is, but I think my quality of life would be better without it!

Thanks for raising this discussion, Dave.:)

RN-PA, RN · Jan 21, 2004

My Mom has fibromyalgia and chronic hip pain (bursitis), so she's on a lot of meds, and is narcotic-dependent to manage the pain and be funtional in her life. I know she takes Elavil (Amytriptyline) and I had heard that Elavil is prescribed for fibromyalgia because it helps with the PERCEPTION of pain. I wondered if it was helpful for others.

Dave ARNP · Jan 21, 2004

About Elavil.

Elavil is a FIRST LINE DRUG for Fibromyalgia. I can't imagine NOT having a Fibro patient on it. A TCA can dramatically reduce the amount of pain a person is having, and can also reduce the amount of narcotics required by the patient.

In FMS, TCA's play an important role, in that sleep cycles greatly effect FMS. Since certain TCA's are known for their ability to produce deep sleep, they do a wonderful job of helping the whole principle of the disease process.

Dave

(Please re-read my first post, as it has been edited to include a rule warning on this thread... for those who've already read it :) )

Hellllllo Nurse, BSN, RN · Jan 21, 2004

MD Terminator-

I have FM and I have sent you a pm.

Dave ARNP · Jan 21, 2004

Hi Hello Nurse!

I got your PM and will be getting back to you shortly.

I also have some general information that I will post here, shortly, as well.

Dave

adrienurse, LPN · Jan 21, 2004

what is fibromyalgia and why is it so difficult to diagnose and explain?

Dave ARNP · Jan 21, 2004

The who what when where why and how of Fibromyalgia Syndrome

This should clear up alot for you.

One of the better (IMHO) pages for FMS.

Dave

aimeee, BSN, RN · Jan 22, 2004

Have you encountered any evidence of SAM-e being beneficial for Fibro sufferers?

Dave ARNP · Jan 23, 2004

Never heard of Sam-E being used.

Doesn't mean it wouldn't work, but it seems these days that there is something new comming out.

I would say the latest "new" thing that shows promise would be the use of Tegretol in Fibromyaliga.

Dave

MrsWampthang, BSN, RN · Jan 23, 2004

Thanks for the info Dave. Can FM be R/t mono like CFS is? I had mono a bout two years ago and have never really felt the same level of energy since. Also seems like I have some of the same symptoms that are listed in the link you posted.

Pam:)

Dave ARNP · Jan 24, 2004

Firstly let me both thank you and apologize. Many of you have sent me lengthy e-mails regarding questions you have about Fibro. I really appreciate you holding my opinion high enough to ask it. Secondly, please accept my sincerest apologizes for not getting back with all of you all sooner.

Rather than going through each message and repeating the same information over and over I'm going to post a rather lengthy reply that will hopefully cover everything you've asked. I've always been told that if you're wondering about it, someone else probably is too :) If there is something that I do miss, please smack me very hard and be kind enough to ask me again.

Firstly, treating FMS requires a very multifaceted approach. Typically, there are five goals we need to reach toward in an effort for the FMS patient to reach optimal functioning. These five goals are Sleep, Fatigue, Pain, Depression and Cognitive Dysfunction. Each of these requires therapeutic measures to be implemented in a hope of improving the FMS patients, QOL.

Many have asked about a Dietary Supplement regimen.

In Advance for Nurse Practitioners November 2003 edition, there was a WONDERFUL list of supplements that are suggested for Fibromyalgia.

I will post this list below.

Folic Acid. 1-10mg/day for months. In taking this supplement, we see a decrease in fatigue and depression. It will also boost immune function.

Vitamin B12. 6-70,000 mcg IM/wk. Again looking at a decrease in Fatigue and depression, as well as pain. Will also see a increase in circulation.

Vitamin C 10-50 g/day. Vitamin C boosts immune function, decreases pain and increases microcirculation.

Magnesium and Malic acid are also suggested by Advance, however I've never used these. They even state that taking these supplements shows a SUBJECTIVE improvement. Perhaps they're something to consider.

Advance for NP's does list several additional supplements, however I am choosing not to list those. The other supplements IMHO could effect the FMS patient in a negative way, and since we're not looking at a night and day difference with ANY supplement, I would never suggest them since we could cause more problems than good. The ones I have posted above are ones that I use in management of FMS.

Neatly, medications used in FMS. I have NEVER seen a FMS patient managed effectively on one drug. Polypharmacy runs rampant in the management of this disease. You simply cannot hit all of the target zones of the disease and use one drug. :: crosses finger:: Maybe in the future.

When it comes to treating the FMS patient, we need to look at four base classes of drugs that IMHO EVERY FMS patient needs to be on. These would be TCA's, Benzos, SSRI's and finally Muscle Relaxants. These drugs treat the fundamentals of the disease and are essential to improving QOL. We should also consider non-narcotic analgesics in this regimen.

Once patients are titrated to an effective dosage of these medications, Narcotic-Analgesics come into play. Again, we should titrate all other non-narcotic medications to an effective dose before using narcotic medication. However in extreme presentations, many people will need the addition of a narcotic analgesic right from the get-go.

In the treatment of FMS, two other conditions must be considered. These would be IBS and Overactive Bladder.

Treatment for them is pretty straight forward, but I will suggest medications for each below.

Drugs from the classes.

Below is a discussion of medications I use in FMS. Please note that these may not be for you, but if you were my patient ... would be drugs I would consider first.

TCA's:

Elavil, Elavil and Elavil. NOTHING has been more studied and proven for FMS. I am a huge fan of it and have seen great results from it.

Typical dosage for Elavil in FMS is 25-50mg QHS. We can titrate accordingly, but the greatest effects in terms of pain relief are usually seen at the lower dosages.

Benzos.

For FMS, I like nothing better than Klonopin. With its long acting duration Klonopin provides enough sedation to keep the FMS'er asleep through the night. WHICH IS CRITICAL to maintaining a balance. Klonopin 1mg QHS is usually what I give, but some will need a lower dose of .5mg.

For those who experience a lot of night time awakening but fall asleep easily, I will usually give Xanax. Doses range from .5 all the way to 1.5 in what I typically give. Since Xanax has a shorter duration, it is sometimes necessary to give it ever four hours at night time.

SSRI's:

I have two SSRI's that I pretty much use exclusively. Firstly, NO SSRI has been more studied in FMS than Prozac. Prozac is a wonderful drug and has more uses than I think we'll ever discover. That said, it's not for everyone. I REALLY dislike using it in kids. However I use it a lot in FMS. If I'm giving Wellbutrin, I almost always give Prozac as the SSRI with it, as they work together beautifully.

For Prozac, 20mg QAM. AM is VERY important. Prozac is the MOST STIMULATING SSRI of ANY. IT WILL keep you awake at night.

Secondly, but my first drug of choice ... is Effexor XR. Simpyl put, IT WORKS! It's the best drug I've ever seen to come out of the SSRI class. For Effexor we start at 37.5mg and increase slowly to a total dose of 150mg. Be warned though, if you suffer from HTN Effexor may not be the drug for you. Effexor can spike your BP. Just something you need to watch for.

Finally, muscle relaxants.

For FMS I have three that I like.

It really depends on the persons presentation when I choose which one to go with.

I'll list them and their dosages, then explain which ones I like for which.

Valium 5-10mg TID (MUST BE GIVEN TID/QID)

Soma BID/TID

Cyclobenzaprine 50-150mg BID with occasionally a smaller dose AM and a larger dose HS.

For patients with FMS presenting with anxiety, 9/10 I give Valium. This allows the drug to serve two purposes and we all know that anxiety can effect pain.

For patients who's pain is intolerable, I usually use Soma. Mind you, that if I have a patient on ANY Hydrocodone containing compound, I do NOT WRITE SOMA. Soma and Lortab are part of a coctail that is very popular in the club scene. Supposedly it gives a rush similar to Heroin. It is not that I am trying to deny patients a medication, or that they don't need a medication ... however our job is to HELP with their problem. Giving them a combination of medication that will produce a Heroin like high? Well, I can't see as how we'd be helping them. Mind you, I do have patients on Soma and Hydrocodone. However I use this combination in patients who get relief from NOTHING else. These patients have also almost always been cleared by an addiction specialist.

When considering a non-narcotic analgesic we have a few options. I'll list them below and then describe where and I why I use them

APAP 500mg QID

Relafen 750 BID

Ultram 50mg two tabs QID PRN NTE 6 tabs QD.

Motrin 800mg TID-QID

Naproxen 500mg TID

Toradol 10mg Q-4-6hrs NTE 10days

APAP is a Band-Aid. Simply put. I use it rarely. If its Sunday night, someone is out of medication and they don't want to come into ER. I'll suggest it.

Relafen is a great drug. It's generally well tolerated and does a good job with the pain. I use it a lot.

Motrin and Naproxen. They're OK. I love 800mg Motrin for back pain. Some patients do REALLY WELL with these. When they do, I'm super happy. They're life is alot easier. They run of meds, Walmart will have it :)

Ultram. This is the drug I use right before someone moves over to a narcotic medication. Honestly, I'd rather give a Vicodin than this, but it's been my expeirence that if you're treating a patient for chronic pain the medical review boards and SBON REALLY EXPECT to see that you've given this. Ultram is a form of a synthetic opioid and many people get great relief from it. I also consider Ultram to have the same abuse potential as ANY schedule II drug, so I observe it's usage closely.

Toradol PO. Toradol has saved MANY of my patients from admission on a PCA. It is a great drug, but you must be aware of the risk of bleeding associated with it. I have several patients who request IV Toradol for pain crisis over ANY narcotic. As a one lady I treated told me "With that Dilaudid stuff you give, I get higher than a kite. Yea, my pain's gone, but it makes me loopy as h**l. That one medicine (Toradol) kills my pain and I still know exactly where I am. I like that!) I've had MANY patients with severe CA pain that I've treated with Toradol IV and allowed them to go home with a few days of it PO. More than one family has said that doing this allowed their loved one to be pain free and spend what little time they had left AT HOME with their loved ones.

I'm going to end this message here, however I will soon be posting part two which will cover narcotic pain medications. I will also be posting a set of lab tests which I suggest for all FMS patients to have.

Best wishes in your pain control!

Dave

(edited for accuracy)