Fibromyalgia Quiz: 5 Questions for Primary Care

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Although fibromyalgia is a very challenging disorder to manage, internal medicine specialists are well placed to help patients receive optimal care, according to Carmen E. Gota, MD, Director of the Fibromyalgia Clinic at the Cleveland Clinic in Cleveland, Ohio.

“The internist is the most important caregiver when it comes to fibromyalgia,” said Dr. Gota, who presented an update on fibromyalgia and other central pain syndromes at the American College of Physicians Internal Medicine Meeting 2018 in New Orleans, Louisiana, this week.

Why is that? Take the quiz to learn some expert insights Dr. Gota shared with Patient Care on the diagnosis, treatment, and management of this heterogeneous and complex condition.

Question 1. 

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The correct answer is A. Exercise

Exercise is essential to fibromyalgia care, as much as insulin is essential for patients with diabetes. “One way to present it to patients is to tell them that fibromyalgia is an ‘exercise deprivation syndrome,’” Dr. Gota said.

Based on meta-analyses, exercise was the only “strong for” therapy-based recommendation in the most recent European League Against Rheumatism (EULAR) revised recommendations¹ for the management of fibromyalgia. Medication, CBT, and hydrotherapy all received “weak for” recommendations based on the critical evaluation of available literature in the field.

Exercise should be graded and sustained, and patients should be advised they will need to exercise for the rest of their lives, Dr. Gota said.

Question 2.

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The correct answer is B. False

While the EULAR guidelines did not come out strongly on recommending multidisciplinary interventions, there is a small group of experts that recommends interventions such as mindfulness, biofeedback, and of course exercise, before medications, according to Dr. Gota. For example, CBT can be extremely helpful for those patients who feel helpless or tend to catastrophize their pain.

Question 3. 

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The correct answer is E. None of the above

Pain is the dominant fibromyalgia symptom, and therefore integral to the latest diagnostic criteria² for the condition. Beyond pain, fibromyalgia is a heterogeneous and complex condition. Symptoms such as non-refreshed sleep or cognitive impairment are common, but not found in every patient. Thus, treatment needs to be individualized, and all patients should be educated on the nature of fibromyalgia, according to EULAR guidelines.

Question 4. 

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The correct answer is C. 50%

Roughly half of the patients who take one of the three US Food and Drug Administration approved drugs for fibromyalgia will experience a >30% reduction in pain, clinical trial data suggest.

“All patients should understand that sole reliance on pills will not help them get better, as medications only work, imperfectly, on half of the patients that take them,” Dr. Gota said.

Large placebo effects have been noted in randomized trials and meta-analyses. A recent review article³ in Pain Management outlines studies of pregabalin, duloxetine, and milnacipran showing that 40% to 61% of treated patients reported >30% pain reduction, and so did 28% to 36% of patients receiving placebo.

The number needed to treat, meaning how many patients have to take a drug for one patient to have a true benefit, is about eight to 10, Dr. Gota said.

Question 5. 

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The correct answer is A. Internist

The internist is best placed to diagnose fibromyalgia, implement care, and make referrals, according to Dr. Gota, who recommends following the “fibromyalgia fingerprint,” a set of factors that might underlie an individual fibromyalgia case:

•  Lack of exercise
• Traumatic events/stress
• Disturbed sleep
• Mood/psychiatric disorders
• Maladaptive responses to pain
• Genetic predisposition

One patient may have a strong family history of fibromyalgia, significant abuse as a child, and post-traumatic stress disorder (PTSD). That patient will need a psychiatrist, psychologist, counseling, therapy, and management of PTSD, as well as education and a physical therapist referral, according to Dr. Gota.

Another patient may have no family history and no history of traumatic events, but may have general anxiety disorder and fear of exercise. “That patient needs the anxiety managed, education, and graded, guided exercise,” she said.

References:

1. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76:318–328.
2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46:319-329.
3. Okifuji A, Gao J, Bokat C, Hare BD. Management of fibromyalgia syndrome in 2016. Pain Manag. 2016;6:383-400.