Pharmacists
Pharmacists
Pharmacists
FM-CFS Canada
FIBROMYALGIA
FOR
PHARMACISTS
2 Management of Fibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.1 Non-Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.1.1 Cognitive Behaviour Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.1.2 Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.1.3 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2.2 Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
2.2.1 Pain Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
2.2.1.1 Tricyclic Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
2.2.1.2 Selective-Serotonin-Reuptake Inhibitors . . . . . . . . . . . . . . . . . . .9
2.2.1.3 Selective-Serotonin-Norepinephrine-Reuptake-Inhibitors . . . . . .9
2.2.1.4 Dopamine Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
2.2.1.5 Pregabalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
2.2.1.6 Tramadol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
2.2.1.7 NMDA-Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
2.2.1.8 Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
2.2.2 Fatigue Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
2.3 Herbals and Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
4 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Acknowledgements:
1 What is Fibromyalgia?
1.1 Introduction
Fibromyalgia (FM) is not a waste paper basket disease. Its symptoms are very
real. Ongoing research is close to procuring diagnostic tools and a better
understanding of the underlying cause. Once defined, one will be closer to
more specific drug therapy for FM.
1.2 Epidemiology
1.3 Etiology
1.4 Diagnosis
1.5 Symptoms
FM patients with pain and fatigue may also experience one or more of the fol-
lowing; body stiffness, increased frequency of headaches or facial pain, sleep
disturbances, digestive complaints (including Irritable Bowel Syndrome
(IBS)), genito-urinary problems, paresthesias especially in the hands and
feet, highly sensitive to cold ambient temperatures, skin complaints including
dry skin , eyes and mouth, and a sensation of swelling of the extremities,
chest muscle pain and shortness of breath, light-headedness and balance
problems, cognitive disorders termed "fibro-fog", memory lapses and "spaci-
ness", Restless Legs Syndrome (RLS), hypersensitivity to the environment
including noise, odours, light and weather patterns, and anxiety and
depression. 1,4,6 Patients may also suffer from Chronic Fatigue Syndrome
(CFS).6
1.6 Pathogenesis of FM
The exact cause of fibromyalgia is not known at this time.1 Increased evi-
dence is pointing to a number of pathophysiologic differences. FM patients
have a decreased amount of neurotransmitters that amplify and distort pain
signals.4 Low serotonin levels,1,2,4 lead to anxiety, depression, pain, sleep
disorders and smooth muscle dysfunction.2
Other hormones and neurotransmitters that are low include cortisol, thy-
rotropin-releasing hormone (TRH), growth hormone, dopamine, epinephrine
and norepinephrine.2,6 Growth hormone is required for muscle repair and
metabolism. Epinephrine and norepinephrine levels lead to erratic elevations
in heart rate and blood pressure. Orthostatic hypotension (lightheadedness),
constricted blood vessels and Raynaud's phenomenon may be present.2
1.6.1 Pain
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MANAGEMENT OF FIBROMYALGIA
There is no "magic bullet" to treat FM. Control of symptoms is currently the
focus of treatment. Goals include improving deep sleep and establishing a
regular exercise program.2
Cognitive Behaviour Therapy (CBT), and exercise are the best studied non-
pharmacological therapies and have shown efficacy in the treatment of FM.14
2.1.2 Exercise
2.1.3 Other
Patients with fibromyalgia have many pain features that are seen in neuro-
pathic pain syndromes,(eg. Diabetic peripheral neuropathy and Herpes Zoster
(shingles)). All of these pain syndromes are chronic in nature. There is a
stimulus-dependent pain sensation accompanied by hyperalgesia/allodynia
and parasthesias.18 These similarities in syndromes have led to the use of
drugs to treat FM pain that have been used in shingles and diabetic pain syn-
dromes.
2.2.1.3 Selective-Serotonin-Norepinephrine-Reuptake-Inhibitors
A 12-week study in 15 patients with FM were assessed before and after treat-
ment with 75mg venlafaxine daily. The primary outcome was the
Fibromyalgia Impact Questionaire (FIQ) and pain score. Depression and anxi-
ety were measured using the Hamilton Depression and Beck Depression
scales, and Beck Anxiety and Hamilton Anxiety scales respectively.
Venlafaxine significantly reduced pain ( F=14.3; p=0.0001) and disability
caused by FM ( F=42.7; p=0.0001). Patient and physician rated anxiety and
depression were reduced significantly.21
2.2.1.5 Pregabalin
Antiepileptic drugs are used widely in the treatment of chronic pain condi-
tions. Pregabalin (Lyrica®) is a gamma-amino-butyric-acid (GABA) analog.14
In Canada it is approved for neuropathic pain associated with diabetic periph-
eral neuropathy and post-herpetic neuralgia.25
ing 450mg per day significantly decreased average severity of pain compared
with placebo ( p = 0.001). Significantly more in the 450mg group had = 50%
improvement in pain than placebo (29% versus 13%, p=0.003). Both the
300mg and 450mg doses per day groups showed significant improvements in
sleep quality and fatigue. Quality of Life measures improved in those on
450mg per day. The most frequent side-effects were dizziness (usually disap-
peared over time), and somnolence.26
2.2.1.6 Tramadol
2.2.1.7 NMDA-Antagonists
2.2.1.8 Opioids
Opioids have been used in some FM patients. They have been used with
mixed results. One theory to explain their ineffectiveness in FM may be that
FM patients already have increased endorphin release. Their receptors are
already full.28
Very little research study of herbs and supplements in FM has been done.4
The internet is abound with therapy "cures" for FM which are very expensive
and not cures.
3 Summary
Once the cause/s are confirmed, then more specific drug treatment can be
studied and available to patients suffering from this disabling, chronic pain
condition.
REFERENCES
11. Wood PB. "Is fibromyalgia a limbic pain disorder" talk at the
Fibromyalgia Awareness Means Everything (FAME) Conference LA California,
Mar 2006.
15. Nielson WR. Jensen MP. Relationship between changes in coping and
treatment outcome in patients with fibromyalgia syndrome. Pain
2004;109:233-241.
19. Sumpton JE, Moulin DE. Treatment of neuropathic pain with venlafaxine.
Ann Pharmacother.2001;35:557-559.
29. Ko GD, Hum A, Traitses GT. Do topical herbal agents provide relief? A
randomized, placebo controlled pilot study of chronic pain patients having
fibromyalgia demonstrated a positive response to topical herbal agents for
pain management. Paper on file. Swiss Medica.