Fibromyalgia

ljr3000 · Apr 7, 2004

I have found some very good information on another thread from a Nurse Practitioner who treats FM. I am going to try to find it and copy it over to here.:)

ritaaina · Apr 7, 2004

i am someone who has fibromyalgia and it is real. i am 48 years old, just finished lvn school and will be taking my boards in 2 weeks. i have had fibromyalgia since i was 15 years old. i have taken human growth hormone to help me make it through nursing school and i did! about 2-3 years ago i was on a cane and did not think i could make it. i do have to take antidepressants and other medications to help me. i am determined to be a nurse no matter what. i have worked in the medical field for 19 years and nursing is what i wanted to do all along other than becoming a doctor. my worst injury now is having carpal tunnel from doing medical transcription for 16 years. i do wish there was a cure for fibromyalgia. if anyone wants more info on it i can tell you about it as i used to be a volunteer for the arthritis foundation. undefined

ljr3000 · Apr 7, 2004

Here is some great info from Dave that I pulled from another thread. He is a Nurse Practitioner and focuses on Fibromyalgia. Hope everyone takes something away from this and maybe even to your present Dr. to try some of these treatments. I know when I was first diagnosed by a Rheumatologist he started me on Prozac for energy and something else (fibro fog) LOL It was in 1995. But with the studying I've been doing on my own it sounds like Dave is right on top of it.

Enjoy!!

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

spiritus · Apr 7, 2004

I am sure in the minds of some others here, PMS does not exist, either. Cause there is NO definitive and objective test to PROVE it does.
Hiya!!
I've been stumped for YEARS as to why redheaded people(in the UK they are known as Gingernuts, for the cookie...the one that tastes like ginger)could tolerate a great amount of pain in certain circumstances....THEN, I read a magazine article from a health publisher that said that the SAME reason that
redheads didn't have a great pain threshold was because of their hair...now, I'm JUST as skeptical as you are, Deb, about scientific angle(we have to have EVIDENCE BASSED MEDICINE in order to do some of the stuff that we do), but to be honest, I truly believe that the human condition is made more difficult by
not having an open mind. IF WE as nurses can't be open minded, how does that tally with our health promotion attempts? If we have apatient who can really, REALLY benefit from, say, aromatherapy, or something else that s/he
wants to learn, who am I, as the nurse, to naysay that patient?
PMS/T(Tension-English definition) is quite prevalent here; my own suspicion
is that women here have a great deal of stress....and I will venture to say that stress is ***THE** number one killer of humans...followed closely by
malnutrition. That is MY two pence on the subject...have a great day, enjoy
what you do, and if you don't, look for a place that you can really be happy.
Blessings, Spiritus

lukezgal · Apr 7, 2004

sigh... The practice of ............medicine is based on principles of diagnostics and treatment. what a chaotic world it would be if we were to accept anyones vague complaint about anything they were experiencing at any given time as a new disease.....

But Veetach you are forgetting one sinple factor... it is not just ONE person who is suffering here... it's a LOT of people all over the WORLD!!!!

:nono:

SmilingBluEyes · Apr 7, 2004

sigh... The practice of medicine is based on principles of diagnostics and treatment. what a chaotic world it would be if we were to accept anyones vague complaint about anything they were experiencing at any given time as a new disease.....[/quote
sigh...didn't know you practiced medicine. Well excuse me.

missmercy · Apr 7, 2004

"I think pain is a part of life. I am sorry that these people are having discomfort, "

You are right .... pain is a part of life. Obviously, some of us -- those who live with it-- understand that in a very real way. Many of us with FM are not merely "having discomfort" It is PAIN!!!!! Not every one experiences the same level of pain, the same frequency or the same duration..... nevertheless, for many of us it is miserable ( many of us are functioning as productive members of society and even doing such a darn good job of it that noone -- other than those who really KNOW us would be able to tell that we are in pain!!!)

veetach · Apr 7, 2004

But Veetach you are forgetting one sinple factor... it is not just ONE person who is suffering here... it's a LOT of people all over the WORLD!!!!

Please reread my posts. I did not EVER say I ignored a patients pain, nor did I EVER say that I thought it was "all in their head". I treat my patients with respect no matter what I think about their presenting symptoms. I simply posted a thread asking peoples opinion about Fibromyalgia. Do not even suggest that I am the only person on this board who has suspicions on the validity of this condition.

Do not attempt to tell me what to do with my career, please. And do NOT attempt to condescend to me. You have quite the attitude to label me, "cold hearted and callous". Is this just because I am questioning the validity of Fibromyalgia? No need to get defensive and start calling names here. I have a right to my opinion and I am trying to gain some insight into this problem that we are now seeing in vast multitudes coming into the ER.

RNFROG3, BSN, RN · Apr 7, 2004

Hey--

I was diagnosed with fibromyalgia and I told the MD, I'm sorry I don't believe in that as a diagnoses. She was great. She said how about a symptom of an underlying cause? I said okay but what?? I have been having increasing symptoms of pain in my thumb joints, and extremely stiff legs all the time but excessively after my 12 hr shifts, fatigue (sleeping 16 hrs a day on my days off) oh I only work 2-12hr shifts a week (weekend option). She asked me if i was depressed, I said I don't think soo ..I just got married and my life is better then it has been in 15 years. Other milder symptoms included bloating and craving pasta/rice and slow weight gain.

She thought maybe I had yeast overgrowth syndrome. I took a 15 question test and answered yes to most of them. She then gave me a book called the "The yeast connection" I think that was the name. It described a life style change to a Specific carbohydrate diet. A diet that ws originally made for people with Crohns, diverticulitis and similiar stomach disorders. Eight weeks on the diet and I'm not sore or stiff , losing weight, sleeping like a normal person and feel better.

So maybe fibromaylgia is a quick stopping point for mds who don't know better or for patients who don't want to work for their health. I really believe that it is a symptom not a full diagnoses. But that's just my two cents. :balloons:

RNFROG3, BSN, RN · Apr 7, 2004

Everyone I know with fibromyalgia is A. A hypochondriac B. Clinically depressed or C. a drug seeker. I dont believe in this diagnosis. Throwing oxycontin at aches and pains is like killing mosquitos with a sledgehammer. I am not against appropriate pain meds, especially in the terminal patient....dose 'em up, I say, but not for people who are just not facing life square on...I hurt too after lifting obese geriatrics all night, but Im not going to whine for narcs!

Not all people are any of those things- my drug of choice to treat my symptoms is Motrin. Who are you to judge anothers pain? Unless you suffer daily pain how would you know. Now I'm not a true believer of this diagnoses either but try to walk in anothers shoes instead of blowing them offas crazy, depressed or a drug seeker.

Over-the-hill-Nurse · Apr 8, 2004

I have enjoyed reading the post regarding Fibromylagia. I have learned alot on different perspectives on this illness. But it the last few pages of this thread I have read alot of name calling and putting other nurses on the spot. While I am a avid believer in pain control and making sure my patients are not in pain, I believe that most of the nurses on this thread are just voicing their opinion. It is entirely possible that those nurses who question the diagnosis are trying to find a new way of thinking about it. I also see patients that are frequent flyers who have every diagnosis possible and are only satisfied with narcotic pain relief even when offered other methods of pain control and refuse it. I also believe in the constitution that gives us the right to free speech and the ability to think for ourselves. In defense of Vetach I did not read in any of the posts that this person said that they didn't believe in treating their patients for pain. I myself learned alot from all the people who posted. I had no idea that their were so many FM sufferers that post here. My own daughter also has FM and I have been active in trying to get the best care for her, their are alot of physicians who also don't believe it exists. I also believe they are wrong. And I will continue to try and change people's opinion regarding this illness. But in all fairness, I don't believe that this post or any other we should be down grading another nurse for his or her opinion. As nurses we should also respect our peers and give them the benefit of the doubt.

Over-the-hill-Nurse · Apr 8, 2004

This is a really interesting article in which it states that a new brain scan study comfirms scientifically what fibromyalgia patients have been telling a skeptical medical community for years: They're really in pain.

The results of this study was published in the issue of ARthritis and Rheumatism, The journal of the American College of Rheumatology, may offer the proof of fibromyalgia's physical roots that many doubtful physicians have sought. It may also open doors for further research on the still unknown causes of the disease, which affects more than 2 percent of Americans, mainly women.

The researchers used a super fast form of MRI brain imaging, called functional MRI or fMRI, on 16 fibromyalgia patients and 16 people without the disease. As a result, the study offers the first objective method for corroborating what fibromyalgia patients report they feel, and what is going on in their brains at the precise moment they feel it.

The fMRI gave the unique opportunity to look at the neurobiology underlying the tnederness, which is a hallmark of fibromyalgia. "These results combined with the other work done by our group and others have convinced us that some pathologic process is making these patients more sensitive. For some reason, still unknown, theres a neurobiological amplification of their pain signals." The full article can be found at http://www.med.umich.edu/intmed/rheumatology/fmweb

Other articles that may give insight are:

"Abnormal Pain Memory Helps to Explain Fibromalgia" and "Ordinary Touches Multply into Severe Pain for Fibromalgia Patients"

Both these articles can be found at http://www.Rheumatology.org

this gives some real objective proof that fibromyalgia is a real disease for those who are skeptical and require proof.