Fibromyalgia - Should Internists Manage a Contested Illness? Save

The current issue of ACP Internist discusses the considerable dissent among the medical community about fibromyalgia (FM), its cause, diagnosis and care. This review addresses many concerns with input from well-known experts in rheumatology.

The overview quotes Drs. Daniel Clauw. Fred Wolfe and Robert Katz on their views regarding FM. Clauw explains why this is a pain amplification problem with disordered central pain processing. Wolfe, on the other hand, views these CNS observations as mechanisms of disease expression, not necessarily the cause.

Dr. Wolfe believes there are numerous basic biological, psychological, societal, and individual factors that contribute to the disease. FM patients have less education, are more distressed, and have more life events, such as cancer, heart disease, and kidney disease.

The article reviews diagnosis and management, with rheumatology experts providing guidance on how internists can diagnose and manage patients wisely and with confidence. Some of the high points of the discussion:

• Dr. Wolfe points out the exam is important to the diagnosis and meeting the 1990 criteria. However, the reliability of tender points was not good.
• In 2010 the new, preliminary guidelines no longer require tender points.  Instead the diagnosis is based on symptoms; specifically, a “widespread pain index” that evaluates 19 areas of the body for pain and a “symptom severity score” that analyzes the severity of somatic and cognitive symptoms.
• Dr. Robert Katz uses a screening tool in his office.
• Dr. Leslie Crofford believes fibromyalgia is hard to diagnose because the symptoms are severe and relatively nonspecific, and that many internists fear they're missing something because the patients can be terribly symptomatic.
• Dr. Crofford said that although many conditions may resemble FM (lupus, thyroid disease, spondyloarthritis, rheumatoid arthritis, polymyalgia rheumatica), these are far less common than FM in the primary care setting.
• Dr. Katz discussed the mistake of unnecessary imaging or testing.
• Once the diagnosis is made by the PCP or internist, they can manage FM with agents commonly used in practice.
• Of the 3 FDA approved drugs for fibromyalgia (Lyrica, Cymbalta, Savella), all have a relatively low effect size and carry the risk of adverse effects.
• Experts like to start with tricyclic antidepressants or a gabapentinoid, or a serotonin-norepinephrine reuptake inhibitor (SNRI), such as duloxetine or milnacipran.