CARE GUIDE for Fibromyalgia SUGGESTED GUIDELINES PROCESS IMPORTANT FINDINGS MEASUREMENTS AND VALUES INTERVENTION FOLLOW-UP Confirm Diagnosis History of chronic pain > 3 months The American Pain Society (APS) proposes the following objective criteria for the diagnosis of fibromyalgia:  Widespread pain for at least 3 consecutive months - all of the following are present:  pain in the left side of the body  pain in the right side of the body  pain above the waist  pain below the waist  In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present Use a pressure algometer (dolorimeter) to determine pressure pain thresholds at both lateral epicondyles and the midpoints of the trapezii to aid in diagnosis and assess response to therapy. An abnormal test produces pain at less than 4 kg/cm2 of pressure.  Pain in 11 of 18 tender point sites on digital palpation  Diagnostic tests to rule out other conditions – Complete Blood Count (CBC), Thyroid Stimulating Hormone (TSH), comprehensive metabolic panel- including uric acid, Creatine Phosphokinase test (CPK), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Antinuclear Antibody (ANA), anti-cyclic citrullinated peptide (anti-CCP) antibody, and rheumatoid factor. Hepatitis-C testing, sleep studies, 25-hydroxyvitamin D, transferrin, and pseudogout studies if indicated by history or preliminary lab results  Psychological screening tests if indicated: e.g.,   1-6, 8) 2013 Fibromyalgia Care Guide FINAL 8/2013 Healthways Science and Medical Integrity Begin treatment with pharmacologic and non-pharmacologic therapies Monitor over time to assess treatment progress Copyright © 2009-2013 Healthways, Inc. All Rights Reserved Page 1 SUGGESTED GUIDELINES Pharmacologic Management (1, 3, 4, 5 ,7, 8, 9,10) PROCESS  Prescribe medication based on individual symptoms and functional status 2013 Fibromyalgia Care Guide FINAL 8/2013 Healthways Science and Medical Integrity IMPORTANT FINDINGS MEASUREMENTS AND VALUES the Minnesota Multiphasic Personality Inventory, the Social Support Questionnaire, the Sickness Impact Profile, or the Multidimensional Pain Inventory (MPI) The American College of Rheumatology (ACR) proposes subjective diagnostic criteria. This criteria may be found in the ACR journal Arthritis Care & Research, Vol. 62, No. 5, May 2010, pp 600–610 DOI 0.1002/acr.20140  Functional status, visual analog scale for pain intensity, degree of fatigue and global selfassessment may be evaluated and quantified using tools such as the Fibromyalgia Impact Questionnaire Revised (FIQR) available at: http://www.myalgia.com/FIQR.info INTERVENTION FOLLOW-UP Medication efficacy:  Strong evidence  Amitriptyline: often helps sleep and overall well-being; dose 25-50 mg  Cyclobenzaprine 10-30 mg at bedtime  Modest evidence  Selective Serotonin Reuptake Inhibitor (SSRI)  Serotonin Norepinephrine Re-uptake Inhibitor (SNRI)  Some anti-convulsants, including gabapentin  Newly approved for fibromyalgia:  Pregabalin (Lyrica) 300 or 450 mg per day for pain  Duloxetine (Cymbalta) 30 mg/once a day x 1 week, then increase to 60 mg/once a day  Milnacipran (Savella) 50 mg bid titrated over 1 week Other individual provider approaches to the treatment of fibromyalgia may include any of the following: topical lidocaine or topical capsaicin,  Re-evaluate and change medication plan as needed Copyright © 2009-2013 Healthways, Inc. All Rights Reserved Page 2 SUGGESTED GUIDELINES Non-Pharmacologic PROCESS 4) Immunizations (11) INTERVENTION tramadol, propranolol at bedtime, clonidine, increased potassium intake, rolaxifene, modafinil, or pramipexole (under investigation) NOTE: See FDA black box warnings for suicidality in children, adolescents and young adults (18-24 yrs) for antidepressants and secondary to antiepileptics  Strong Evidence  Cardiovascular exercise  Cognitive Behavioral Therapy  Patient Education  Multidisciplinary (combinations of above)  Moderate Evidence  Strength Training  Acupuncture  Hypnotherapy  Biofeedback  Balneotherapy  Refer to rheumatologist, pain specialist, physiatrist, or psychiatrist  Start concurrently with medication management  None  Refer to specialist(s)  Patients not responding to therapy  Influenza Vaccination  Document patient has an influenza vaccination each year and document if adverse event occurs   Pneumonia Vaccination  Document patient has received a pneumonia vaccination and document if adverse event occurs  (1, 4, 5) Referral (3, IMPORTANT FINDINGS MEASUREMENTS AND VALUES 2013 Fibromyalgia Care Guide FINAL 8/2013 Healthways Science and Medical Integrity FOLLOW-UP  Begin one or more therapies and add additional as needed  Coordinate care and monitor patient progress as needed Administer vaccination yearly  Yearly Administer pneumonia vaccination to all patients once between 19-64 years of age, with a booster given to those who are age 65 and older, if at least 5 years have passed since their previous vaccine  As indicated Copyright © 2009-2013 Healthways, Inc. All Rights Reserved Page 3 These guidelines are intended as an educational reference and not as a substitute for the clinical judgment of the treating physician concerning appropriate and necessary care for a specific patient. These guidelines are based on the clinical references listed at the end of the document. Note that a specific treatment or therapy listed may not be a covered benefit for all individuals. Please check the individual’s eligibility and benefits plan. Reference List 1. Buckhardt CS, Goldenberg D Crofford L Gerwin R Gowens S Jackson K Kugel P McCarberg W Rudin N Schanberg L Taylor AG Taylor J Turk D. Guideline for the management of fibromyalgia syndrome pain in adults and children. American Pain Society (APS); (2005), -109. 2007. 3-10-2007. [Buckhardt CS, Fibromyalgia Guideline] Reviewed 5/28/13 2. Gerwin RD. A review of myofascial pain and fibromyalgia--factors that promote their persistence. Acupunct Med. 2005;23:121-34. [Gerwin RD, Acupuncture 2006] Reviewed 5/28/13 3. University of Texas, School of Nursing, Family Nurse Practitioner Program. Management of fibromyalgia syndrome in adults. Austin (TX): University of Texas, School of Nursing; 2009 Austin, Texas. [University of Texas, Fibromyalgia Treatment Guideline] Reviewed 5/28/13 4. Hassett AL, Gevirtz RN, Nonpharmacologic Treatment for Fibromyalgia: Patient Education, Cognitive-Behavioral Therapy, Relaxation Techniques, and Complementary and Alternative Medicine. Rheumatic Disease Clinics of America. 35 (2009) 292-407. Reviewed 5/28/13 6. Wolfe F, Clauw D, Fitzcharles M, Goldenberg D, Katz R, Mease P, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. 2010 American College of Rheumatology: Vol 62, No.5, May 2010 pp 600-610 Reviewed 5/28/13 8. Boomershine CS, Crofford, LJ. A symptom based approach to pharmacologic management of fibromyalgia. Nat. Rev. Rheumatol. 5, 191-100 (2009); doi:10.1038/nrrheum.2009.25 Reviewed 5/28/13 5. American Academy of Family Physicians. Fibromyalgia in Family Medicine: Challenges in Pain Management, 2011 American Academy of Family Physicians – Pain Management Series Reviewed 5/28/13 http://www.aafplearninglink.org/index.aspx 7. Bennett RM, Friend R, Jones KD, Ward R, Han BH, Ross RL. The Revised Fibromyalgia Impact Questionnaire (FIQR): Validation and Psychometric Properties. Arthritis Research & Therapy. 2009;11(4):R120. Reviewed 5/28/13 9. FDA Proposes New Warnings About Suicidal Thinking, Behavior in Young Adults Who Take Antidepressant Medications. FDA. 2007. 7-62007. [FDA Warning: Antidepressants] Reviewed 5/28/13 10. FDA. Information for Healthcare Professionals Suicidality and Antiepileptic Drugs. FDA. 1-31-2008. 2-7-2008. Updated 12-16-2008 [FDA – Antiepileptic Drugs] Reviewed 5/28/13 11. Recommended Adult Immunization Schedule. MMWR January 28, 2013, Vol. 62 http://www.cdc.gov/mmwr/pdf/wk/mm62e0128.pdf 2013 Fibromyalgia Care Guide FINAL 8/2013 Healthways Science and Medical Integrity Copyright © 2009-2013 Healthways, Inc. All Rights Reserved Page 4