Managing fibromyalgia – top tips and getting to grips! Dr A Abhishek Clinical Associate Professor University of Nottingham Honorary Consultant Rheumatologist Nottingham University Hospitals NHS Trust Overview • • • • Cases – yours and mine Understanding the disease Symptoms and signs Management – Non-pharmacological • Education • Therapy – Pharmacological Cases – your • • • • Story Findings Tests Progress Cases – mine • • • • Story Findings Tests Progress Epidemiology Prevalence – 2% in the western world Females >> Males Age Deprivation Do you believe in fibromyalgia being a true diseases entity? Central augmentation Augmented sensory input Pathophysiology serotonin norepinephrine dopamine Autonomic nervous system 5-HT transporter COMT gene acute injury accidents chronic ill health Hypothalamic pituitary axis cortosol IGF 1 growth hormone Genetic Physical stressors Psychosocial factors Sleep disturbance: reduced delta wave sleep abuse deprivation mental health Pathophysiology ↓ sleep Strategies aimed at increasing sleep improve symptoms ↑ pain ↓ IGF1, GH ↓ sleep ↓ microinjury repair ↑ pain ↑ fatigue Symptom complex in fibromyalgia Anxiety Pain Psychological symptoms Depression Patient Somatic symptoms Fatigue Distress Tiredness Paresthesiae Disability Poor sleep IBS/GORD Panic disorder Poor memory Dificulty coping Asthma, cough, migraine Key symptoms in fibromyalgia Unrefreshing Widespread Back Limbs Constant Pain T-M joint Sharp Insomnia Sleep Stabbing Not activity related Non-restorative sleep Poor quality Look more carefully… Early life experiences FMS Recent Social significant events and family life Examination Mimes and investigations • • • • • • • FBC U&E, LFTs, calcium, phosphate, TSH ESR, CRP Vitamin D Coeliac screen – anti-TTG antibodies Immunoglobulin electrophoresis ANA, CK Patient’s concerns • • • • • • • What is wrong with me? Why have I got it? Will I get worse - wheelchair? Is it in my mind ? Can I be cured? There is no cure is there ? Dr Google says .. what do you think? Patient’s concern …. rarely addressed • • • • • • • What is wrong with me? ..fibromyalgia Why have I got it? …don’t know, I will refer.. Will I get worse - wheelchair? …may be Is it in my mind ? ….?.... Can I be cured? NO There is no cure is there ? YES, that’s right Dr Google says .. what do you think? …..ask the specialist who you see in hospital Treatment • • • • • • • Accept symptoms are real Diagnose with confidence Empathise about the condition Explain about the disease Educate about the treatment Non-pharmacologic, pharmacologic treatment Follow-up Non pharmacological treatment • Heated pool treatment +/- exercise • Individually tailored exercise programmes including aerobic exercise and strength training • Cognitive behavioural therapy • Other therapies such as relaxation, rehabilitation, physiotherapy and psychological support Pharmacological treatment • Simple analgesics • Weak opiates • Tramadol: do not prescribe potent opioids or chronic NSAIDs • Antidepressants: amitriptyline, fluoxetine, duloxetine, milnaciprane and pirlindole • Tropisetron, pramipexole and pregabalin Drugs and the lot Despite adequate pain relief, these interventions do not translate into improved quality of life on HAQ or on SF 36 What do you do? Most patients agree to a management plan for symptomatic benefit GP Pain clinic Hospital MDT clinic Therapy Getting to grips • • • • • • Drug therapy is not mandatory. Shared decision-making Augment placebo and reduce nocebo response Start low, go slow Monitor for efficacy, tolerability, and safety Promote long-term drug-free self-management Any questions Any questions Thank you