Peace:
• It does not mean to be in a place where
there is no noise, trouble or hard work, it
means to be in the midst of those things
and still be calm in your heart.
• Author unknown
An Integrative Approach
to Fibromyalgia
Julie Reardon M.D.
Fellow: Arizona Center for Integrative
Medicine
Tucson,AZ
Perception: All in my head?
CNS Imbalance
• Response to antidepressants
• Cluster of symptoms
• Somatizer
“a person with frequent physical complaints for
which no organic basis is found”
Clinical Characteristics of
Fibromyalgia
• Chronic widespread pain
• Diffuse tenderness
• Fatigue
• Sleep disturbance
• Cognitive problems (e.g. forgetfulness)
• Depression/anxiety
• Stiffness
• Impaired social and/or occupational
functioning
ACR Criteria
• History of widespread pain > or = 3 mo
• Bilateral
• Diffuse: Above and below waist
• Axial skeleton pain
• Pain in 11 or 18 tender point sites
(4 kg of force)
Who?
• 2% U.S. Population (3-6 million people)
• Middle age
• Prevalence increases with age
• 6X greater in females than males
• Half of all cases present after physical
or emotional trauma or flu-like illnesses
Work-up for acute/subacute
sx
• Listen….History taking
• “virtually no work up necessary if symptoms
have lasted for years and history is classic”
• If not done already:
• ESR, CRP
• CBC, CMP
• TSH, 25(OH) vitamin D
Further work-up based on
clinical findings
• Rheumatic markers: ANA, RF, antibodies
• Vitamin Deficiencies: D, b12, folate
• Plain x-rays
• MRI of head or spine for neuro sx
• Sleep study
• Restless legs: (iron)
• Mg deficiency
Diagnosis: History of Pain
“I hurt all over.”
• The more widespread, the more likely
to be fibromyalgia.
• Often unpredictable
Diagnosis: Symptoms and
Co-morbid Syndromes
• Somatic symptoms
• Fatigue (not improved by rest or exercise)
• Memory or concentration issues
• Insomnia and sleep disturbances
• Co-morbid syndromes
– Irritable bowel
– Interstitial cystitis
– Headaches
– TMJ
Treatment
• Nonpharmacologic
• And
• Pharmacologic
• individualized
MEDICATIONS
• STRONG EVIDENCE:
– dual reuptake inhibitors
• Cyclic compounds: amitryptyline, cyclobenzaprine
• SNRI’s: milnacipran, duloxetine
– Alpha-2-delta ligands: pregabalin, (gabapentin)
• MODEST EVIDENCE:
– Tramadol
– SSRI’s
– Dopamine agonists
MEDICATIONS
• WEAK EVIDENCE
– Growth hormone
– 5-hydroxytryptamine (5-HTP)
– SAMe
• NO EVIDENCE
– Opioids, steroids, nsaids, benzos,
guaifenesin
Approved Medications
Clinically Used Meds
• Alpha-2-delta ligands: block neuronal
excitability
– Pregabalin (Lyrica)*
– Gabapentin (Neurontin)
• Serotonin/NE reuptake inhibitors:descending
pain inhibitory pathways (SNRI)
– Duloxetine (Cymbalta)*
– Milnacipran(Savella)*
• Cyclic medications
– TCA’s
– Cyclobenzaprine
Blocking Neuronal
Excitability
Facilitation
(lyrica/neurontin Inhibition
block on this side) (SNRI’s work this side)
• Substance P • Anti-nociceptive
– Decrease SP pathways
release in – Norepinephrine
inflammatory • Serotonin
states • Dopamine
Glutamate – Opiods
– GABA
– Inhibit SP-
induced – Cannabanoids
glutamate – Adenosine descending
release
Pregabalin (Lyrica)
• See effect within 1-2 wks
• Most common side effects: dizziness,
somnolence, weight gain
• 300-450 mg per day (max dose)
– Bid doses
– Start 75 mg bid
– Can increase after 1 week
– 6 mo trials: show sustained efficacy
Patients with fibromyalgia may be more sensitive to
medications.
Gabapentin(Neurontin)
• Reduction in fibromyalgia-associated
pain
• Most common side effects: dizziness,
sedation, lightheadedness
• Not FDA approved for fibromyalgia
• Some research with 1200-2400mg/day
relief vs placebo…
Duloxetine (Cymbalta)
right side of pathway to
inhibit pain perception
• SNRI
• Use in depression,anxiety, diabetic
peripheral neuropathy, and fibromyalgia
• FDA recommended dose for fibro: 60
mg/day
• Start at 30 mg/d for 1 wk
Milnacipran (Savella)
• SNRI
• Indicated for fibromyalgia
• Dosing
– Day 1: 12.5 mg
– Days 2-3: 12.5 mg bid
– Days 4-7: 25 mg bid
– After day 7: 50 mg bid
– Nausea/headache/constipation
Nonpharmacologic
Therapies
• Strong Evidence:
– Education
– Aerobic exercise
– Cognitive behavior therapy
• Modest Evidence:
– Strength training
– Hypnotherapy, biofeedback, water therapy
Nonpharmacologic
Therapies
• Weak evidence
– Acupuncture
– Chiropractic
– Manual and massage therapy
– Electrotherapy
– Ultrasound
• No evidence
– Tender (trigger) point injections
– Flexibility exercise
Exercise
• Improved mood
• Improved pain
• Not fatigue
• High attrition rate
• Start with pedometer, get outside, visual
cue…transition into other exercise
Cognitive Behavioral
Therapy
• Referral indicates to them “all in your head”
• Teaches skills to improve illness, such as
changes in thoughts and behaviors
• Improves pain, fatigue, mood
• Alters brain chemistry like the DRUG!!!
– Goal setting
– Relaxation training
– Meditation
– Communication stills training
– Strategies for relapse prevention
(moodgym.anu.edu.au) (books)
Stepwise Integrated
Treatment
SLEEP TRIAL OF CBT TX CO-
HYGEINE, MED MORBID
XERCISE EVIDENCE ISSUES
DIET BASED
SUPPLE-
MENTS
Sleep Hygiene
• Regular hours
• Avoid caffeine, nicotine, and alcohol
• Avoid diet supplements and decongestants
• Noise/light reduce
• Warm bath
• Melatonin 0.3-3 mg 45 min before
• Valerian/lemon balm
• Try to avoid prescription meds
Valerian
• Takes 7-10 days
• Reduce anxiety/ improve sleep
• 2 grams crude herb before bed. Follow
directions on extracts.
• 30 min before sleep
• German health authorities approved
>3yrs, WHO >12 yrs
Lemon Balm
• Promote rest, ease anxiety, improve
mood
• 1-3 grams per day
Rhodiola rosea
• Adaptogen from E Europe and Asia
• Anti-depressant activity
• Phase III DBPCT study in chronic fatigue showed
SHR-5 extract (576 mg extract/day) exerts anti-
fatigue effect that increases mental performance,
ability to concentrate and decreases cortisol
response to stress
• Dose in small clinical trials: 300-600 mg/day
standardized to 3% rosavin (purple Nature’s way)
Ashwagandha
• In India and Middle East: used to
increase vitality and longevity, also for
treatment of fatigue, nervous
exhaustion, anxiety, insomnia and GI
disorders
• No data for fibromyalgia but may be of
benefit in certain patients
• For wired/tired feeling
SAMe
• Not really studied for fibromyalgia (weaker)
• 28 studies: meta-analysis for depression
• Statistically and clinically significant outcomes
• Compared with conventional antidepressant
pharmacology, SAMe similar outcomes
• Can increase neurotransmitters
• Stimulating: side effects: mild insomnia,
nervousness, HA
• Do not use in bipolar disorder
• 200 mg bid, increase q3d up to 1200 mg/d
Building blocks for
neurotransmitters
(B12/folate)
• PPI, diabetic meds, vegetarians, atrophic
gastritis: B12 deficiency
• Methylmalonic acid (MMA) elevates before
b12 looks low
• If b12 less than 200, LOW, if less than 400,
check MMA
• B12 1000-2000 mcg daily
• If Homocysteine elevated: supplement with
folate
LIVE IT Health
• Learn: Education is powerful
• Incorporate: Nutrition/Sleep
• Vitalize: Rx and herb
• Exercise
• Imagine: CBT/ mind-body
• Think: Implement changes/empower
Key Points
• 1. Fibromyalgia is not a deteriorating
disease. (does wax/wane)
• 2. It is a multisystem disorder that may
include pain, depression, anxiety,
nonrestorative sleep, and exercise
deconditioning.
• 3. It often coexists with other rheumatologic
diseases and during disease flares.
Thank You!
Resources
• NIH National Center for Complementary and
alternative Medicine (NCCAM): CAM and
Fibromyalgia: At a Glance
http://nccam.nih.gov
• Office of Dietary Supplements(http://dietary-
supplements.info.nih.gov)
• Know Fibro: Fibroguide(www.knowfibro.com)
• Fibromyalgia Information Foundation
(www.myalgiateam.com)
• Review definition of fibromyalgia: includes
widespread for greater than 3 months, but
also generalized fatigue, sleep disturbance,
and often depression and/or anxiety.
• History taking and LISTENING to the patients
are essential for diagnosis and for treatment
plan.
• Treatment includes nonpharmacologic and
pharmacologic approaches which optimize
neurotransmitters.
• Exercise will not improve the fatigue of FM,
but will improve mood and pain.
• Opiods are not indicated.
• Current pathophysiology hypothesis suggest
FM is multifactorial, including an interplay
between environment, genetic, and