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FIBROMYALGIA PRACTICAL STRATEGIES FOR DIAGNOSIS AND

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					    Part 6 of 6
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    Fibromyalgia: Practical Strategies for Diagnosis and Management Part 6 of 6



                FIBROMYALGIA: PRACTICAL STRATEGIES
                FOR DIAGNOSIS AND MANAGEMENT
    FACULTY:                                                                               FACULTY DISCLOSURES:
    Bill McCarberg, MD                                                                     NPWH policy requires all faculty to disclose any affiliation or rela-
    Family Practitioner, Southern California Permanente Medical Group                      tionship with a commercial interest that may cause a potential, real,
    Escondido, California                                                                  or apparent conflict of interest with the content of a CE program.
    Adjunct Assistant Clinical Professor                                                   NPWH does not imply that the affiliation or relationship will affect
    University of California at San Diego                                                  the content of the CE program. Disclosure provides participants
    San Diego, California                                                                  with information that may be important to their evaluation of an
    Joyce Peck Carlone, MN, RN, FNP-BC, CCRC                                               activity. Faculty are also asked to identify any unla-
    Nurse Practitioner, Division of Rheumatology                                           beled/unapproved uses of drugs or devices described in their pre-
    Emory University                                                                       sentation.
    Atlanta, Georgia                                                                       Bill McCarberg, MD, serves on the speaker’s bureau for Purdue,
                                                                                           Pfizer, Mylan, Merck, Lilly, Ligand, PriCara, Forest, Endo, Abbott,
    Daniel J. Clauw, MD
                                                                                           Cephalon, King, and NeurogesX.
    Professor of Anesthesiology, Medicine (Rheumatology), and Psychiatry
    University of Michigan                                                                 Joyce Peck Carlone, MN, RN, FNP-BC, CCRC, has no financial
    Director, Chronic Pain and Fatigue Research Center                                     relationships relevant to the content of this CE activity.
    Ann Arbor, Michigan                                                                    Daniel J. Clauw, MD, serves as a consultant for Pfizer, Lilly, Forest,
    Susan Wysocki, WHNP-BC, FAANP                                                          Cypress Bioscience, Pierre Fabre, UCB, Jazz Pharmaceuticals, and Merck.
    President and CEO, National Association of Nurse Practitioners in Women’s Health       He also received grants or research support from Forest and Pfizer.
    Washington, DC                                                                         Susan Wysocki, WHNP-BC, FAANP, serves on the advisory board of
                                                                                           Bayer HealthCare, Teva, Upsher-Smith, Boehringer Ingelheim,
    INTENDED AUDIENCE:                                                                     Novo Nordisk, GlaxoSmithKline, Trojan, Watson, Azur, Church &
    This continuing education (CE) activity has been designated to                         Dwight, and Qiagen. She also serves on the speaker’s bureau for
    meet the educational needs of nurse practitioners (NPs) involved in                    Bayer HealthCare, Teva, Novo Nordisk, and Boehringer Ingelheim.
    women’s health.                                                                        DISCLOSURE OF UNLABELED USE:
    CE Approval Period: May 2011 through June 30, 31,
    CE Approval Period: June 1, 1, 2011 through May 20122012
                                                                                           NPWH policy requires authors to disclose to participants when they
              Time to Complete This Activity: hour
    Estimated Time to Complete This Activity: 0.5 1.0 hours                                are presenting information about unlabeled use of a commercial
                                                                                           product or device or an investigational use of a drug or device not
    PROGRAM DESCRIPTION/IDENTIFICATION OF NEED:                                            yet approved for any use.
    In this roundtable event, a panel of expert nurse practitioners and
    physicians discuss how to diagnose and treat fibromyalgia (FM) in a                    DISCLAIMER:
    primary care setting. These clinicians provide strategies for over-                    Participating faculty members have determined the editorial content
    coming barriers to FM management and explain how newly pro-                            of this CE activity; this content does not necessarily represent the
    posed diagnostic criteria for FM can be used by primary care                           views of NPWH or Pfizer. This content has undergone a blinded peer
    practitioners.                                                                         review process for validation of clinical content. Although every effort
                                                                                           has been made to ensure that the information is accurate, clinicians
    This program was developed to address educational needs identi-
                                                                                           are responsible for evaluating this information in relation to gener-
    fied by survey and feedback during the 2010 NPWH annual meet-
                                                                                           ally accepted standards in their own communities and integrating the
    ing. NPs show a strong interest in fibromyalgia; a survey emailed to
                                                                                           information in this activity with those of established recommenda-
    10,800 NPs garnered nearly 1000 responses. The questions and dis-
                                                                                           tions of other authorities, national guidelines, FDA-approved package
    cussion following a half-day pre-conference session on issues of pain
                                                                                           inserts, and individual patient characteristics.
    in women provide the basis for the information in this activity.
                                                                                           SUCCESSFUL COMPLETION OF THE ACTIVITY:
    EDUCATIONAL OBJECTIVES:                                                                Successful completion of this activity requires the participant
                                                                                           Successful completion of this activity requires the participant to:to: (a)
    Following completion of this CE program, participants should be                        (a) read learning objectives, disclosures, and disclaimers; (b)
                                                                                           read thethe learning objectives, disclosures, anddisclaimers; (b) study
    better able to:                                                                        the material in the learning activity; (c) during the approval period:
                                                                                                material in the learning activity; (c) during the approval period,
        ® Evaluate fibromyalgia’s neurologic effects and implications                      1. log on to the NPWH web site (http://www.npwh.org), click on
                                                                                           (1) log on to the NPWH website(http://www.npwh.org), 2. (2) click
          for treatment.                                                                   CE Activities in in Professional Education dropdown at the top of the
                                                                                           on CE Activities the the Professional Education dropdown at the top
                                                                                           page, page, the Fibromyalgia: Practical Practical for Diagnosis
                                                                                           of the3. open(3) open the Fibromyalgia: Strategies Strategies for and
        ® Implement current diagnostic and management strategies,                          Management: Management post-test and evaluation form, (4) print
                                                                                           Diagnosis andNewsletter #6 post test and evaluation, 4. print out the
          including integrated care and responsible prescribing of                         evaluation and post test, 5. complete and return the activity evaluation
                                                                                           out the post-test and evaluation form, and (5) complete and send
          pharmaceutical agents.                                                           and the post-test answers to the address or fax to the on the or fax
                                                                                           onlypost-test answers only and evaluation formnumberaddress post-
                                                                                           test/evaluation form, (d) to receive CE credit, a score of 70% or better
                                                                                           number on the form, and (d) earn a score of 70% or higher on the
    ACCREDITATION STATEMENT:                                                               on the post test is required.
                                                                                           post-test to receive CE credit.
    This activity has been evaluated and approved by the Continuing
    Education Approval Program of the National Association of Nurse                        COMMERCIAL SUPPORT:
    Practitioners in Women’s Health (NPWH) for 1.0 contact hour of                         This program is made possible by an educational grant provided by
    CE credit, including 0.5 contact hours of pharmacology content.                        Pfizer.


1                                                                                                Women’s Health Care: A Practical Journal for Nurse Practitioners

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Fibromyalgia: Practical Strategies for Diagnosis and Management Part 6 of 6




M
       rs M is a 69-year-old woman who presents with
       achiness in all of her muscles and difficulty
       getting up the stairs due to leg weakness. She tells
       you that she has to use her arms to push herself
off the toilet. She has been struggling with this for the
last 4 months and feels for certain it is just because she
is getting old. Her mother died in her late 60s and her
father died of a myocardial infarction at age 62. She
never thought she would live this long and believes
her symptoms are just the decline to death. Her sleep
has been disrupted, which she thinks comes from
her inability to exercise. She used to find pleasure in
exercise, but now she just does not have the energy.

Wysocki: Some patients believe that their symptoms
are their “lot in life.” Many do not seek treatment, even
when the pain and fatigue are interfering significantly
with daily life, because they are convinced that their
symptoms are inevitable.

Carlone: I would start by asking her for more details
about the pain that she is feeling. Where does it hurt
the most? Is she always in pain, or are some times worse
than others? (See “Fibromyalgia: Practical Strategies
for Diagnosis and Management,” a CE publication
available online.)

McCarberg: From her description, it is hard to tell
whether the cause of the pain and muscle weakness
is inflammation, neurologic dysfunction, a pain
syndrome, or something else (TABLE 1). The physical
exam and review of her vital signs may provide insight
into the cause of her symptoms. I would probably order                    sedimentation rate (ESR) and C-reactive protein (CRP)
a basic chemistry panel, along with an erythrocyte                        to check for inflammation.

                                                                            Mrs M reports that the worst pain is in her shoulders and
                                                                            pelvic area. She is very stiff for at least an hour every
  Misdiagnosis of Polymyalgia Rheumatica                                    morning. The physical exam shows tenderness at 16 of
                                                                            18 points. There is no evidence of muscle atrophy, and
  A retrospective study of patients who had been
                                                                            strength in the proximal muscles of her arms and legs is
  incorrectly diagnosed with polymyalgia rheumatica
                                                                            rated 4+/5. You do not observe any deformities, swelling,
  revealed that correct diagnosis—involving a variety
  of conditions—was generally made within 3 months                          or redness of her joints. Her weight and all vital signs are
  of the initial diagnosis. Indications that the diagnosis                  stable. Her ESR is 82; the rest of the screening lab results
  was incorrect included continuous pain (vs nighttime                      are not helpful.
  and morning worsening) and pain that did not improve
  rapidly with corticosteroid treatment.                                  Wysocki: What would you suspect, based on these
  Reference                                                               findings?
  Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Olivieri I. The
  spectrum of conditions mimicking polymyalgia rheumatica in a
  defined region of northwestern Spain [abstract]. Arthritis Rheum.       Carlone: The patient’s age, along with the physical exam
  2000;43(suppl):S345.                                                    and lab results, suggest polymyalgia rheumatica (PMR).



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 Fibromyalgia: Practical Strategies for Diagnosis and Management Part 6 of 6



                                                                                                             to polymyalgia or are a
                                                                                                             side effect of prednisone
                                                                                                             administration.     Many
                                                                                                             patients      live   with
                                                                                                             untreated FM for years
                                                                                                             because their ongoing
                                                                                                             symptoms are attributed
                                                                                                             to another diagnosis
                                                                                                             or a side effect of
                                                                                                             medications.

                                                                                                             Wysocki:  How would
                                                                                                             you counsel this patient
                                                                                                             about FM?

 also would review the components usually made in        including drugs (TABLE
IPMR is a clinical diagnosis, which is of FM management,Carlone: I would explain the difference between PMR
 patients older than 50—frequently women if indicated (TABLE 4).
3), sleep hygiene, exercise, and counseling, over age   and FM, describing how the course of the disease and
60—who complain of neck, shoulder girdle, and pelvic                  their treatments differ. PMR is usually self-limited
girdle pain for at least 4 weeks.1 ESR or CRP levels are              with adequate treatment. In contrast, FM tends to be a
usually high in PMR.                                                  chronic disease. Pain is a common feature of both, but
                                                                      in PMR, it is usually confined to the neck, shoulders,
Wysocki: How do you manage patients with PMR?                         and back. Morning stiffness is a hallmark of PMR. It
                                                                      may be helpful to explain the different types of pain
Carlone: Steroids are usually effective in treating the               and their etiologies (TABLE 2). I would screen her for
symptoms of PMR. Patients with PMR should be                          FM. The proposed ACR criteria provide a good tool to
referred to a rheumatologist for possible screening for               assess the likelihood of FM.
giant cell arteritis (GCA).2                                              I also would review the components of FM
                                                                      management, including drugs (TABLE 3 on page 4), sleep
  You make the diagnosis of PMR and start Mrs M on 30 mg              hygiene, exercise, and counseling, if indicated (TABLE 4
  predisone, with a fast taper to 12 mg. When the patient             on page 4).
  returns for follow-up at 3 months, she reports that her
  energy is better and her muscle strength has improved: “I
  do not need my neighbor to open jars for me anymore!”
  However, she still feels achy and is sleeping poorly. “The
                                                                      Summary
  prednisone really helps the deep, boring ache in my
  shoulders and back, but it also makes my sleep worse. I             Despite frustration that her pain and fatigue continue,
  am just tired all day long.”                                        Mrs M is relieved to hear about the additional treatment
                                                                      strategies you propose: “I was worried you’d think I was
McCarberg: PMR symptoms can return if steroids are                    just an old complainer,” she says. She agrees to try an
tapered too fast. However, it does not sound like this is             agent approved for the treatment of FM (TABLE 5 on
the problem here. Prednisone has improved the PMR,                    page 4) for 3 months and hopes she can gradually start
but the ongoing achiness, poor sleep, and daytime                     exercising again. Because of her sleep disruptions,
fatigue suggest that there is another etiology for these              either duloxetine or pregabalin represent good choices
sympt oms.                                                            for pharmacologic treatment. n

McCarberg: Prednisone treatment dramatically improves                 References
polymyalgia. Her remaining symptoms, however, suggest                  1. Healey LA. Polymyalgia rheumatica and the American Rheumatism
                                                                          Association criteria for rheumatoid arthritis. Arthritis Rheum.
fibromyalgia (FM) as a comorbidity. I find that many                      1983;26:1417–1418.
clinicians don’t look further once they have an initial
                                                                       2. Mandell BF. Polymyalgia rheumatica: Clinical presentation is key to
diagnosis, and they assume these symptoms are related                     diagnosis and treatment. Cleve Clin J Med. 2004;489-495




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Fibromyalgia: Practical Strategies for Diagnosis and Management Part 6 of 6




                                                                    SUMMARY. Despite frustration that her pain and fatigue
                                                                    relieved to hear about the additional treatment strategies
                                                                    was worried you’d think I was just an old complainer,” s
                                                                    agrees to try an agent approved for the treatment of FM
                                                                    months and hopes she can gradually start exercising ag
                                                                    sleep disruptions, either duloxetine or pregabalin repres
                                                                    for pharmacologic treatment.




                        References


                        1. Healey LA. Polymyalgia rheumatica and the American Rheumatism
                                                        4
                            Association criteria for rheumatoid arthritis. Arthritis Rheum 1983; 26:1417–

				
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