Fibromyalgia

Question 1

How is fibromyalgia characterized?

Answer 1

1. Chronic widespread pain
2. Increased tenderness
3. Unrefreshing sleep, fatigue & cognitive dysfunction not attributable to other disease states

Question 2

What factors are associated with the development of fibromyalgia?

Answer 2

Trauma

Adverse life events

Mood disorders (anxiety, depression)

IBS

Irritable bladder

Cold intolerance

Paresthesias

Question 3

What are the Goals of Therapy in Fibromyalgia?

Answer 3

• Reduce pain, fatigue, psychological distress and sleep problems
• Improve physical and emotional well-being, functioning and quality
• Address associated conditions on an individual basis
• Promote self-management via individual and group education

Question 4

In what age range do symptoms occur?

Answer 4

30 to 60 years of age

Question 5

True or False: 80-90% are women

Answer 5

TRUE

Question 6

True or False: Fibromyalgia can coexist with other conditions associated with chronic pain

Answer 6

True

Question 7

What is first-line in Fibromyalgia? Why?

Answer 7

Nonpharmacologic management

Lack of strong data to support the use of medications

Question 8

What benefits can patient education provide in fibromyalgia?

Answer 8

Improves pain, sleep, fatigue, quality of life and the 6 minute walk test

Question 9

How long can the benefits of patient education last in fibromyalgia?

Answer 9

At least 3-12 months

Question 10

What type of educational approach is recommended for fibromyalgia?

Answer 10

Patient-entered approach to education

Question 11

What role does CBT play in fibromyalgia management?

Answer 11

Ongoing CBT sessions are a key component of multidisciplinary treatment

Question 12

What components are included in a multidisciplinary fibromyalgia program?

Answer 12

Education

Self- management

Nonpharmacologic pain reduction techniques

Graded aerobic exercises

Sleep hygiene

Stress management

Cognitive behavioural therapy

Question 13

Which types of exercise can improve function, symptoms and wellbeing in fibromyalgia?

Answer 13

Supervised aerobic exercise
Walking programs
Aquatic exercise
Graded exercise programs
Strength training
Tai chi

Question 14

What are nonpharmacologic pain-reduction techniques used in fibromyalgia?

Answer 14

Cold
Heat
TENS
Massage
Relaxation techniques (i.e., biofeedback, meditation, & hypnosis)

Question 15

True or False: Electroacupuncture appears to be more effective than acupuncture.

Answer 15

TRUE

Question 16

Why is drug treatment for fibromyalgia largely empiric?

Answer 16

Because the ethology of fibromyalgia remains unknown

Question 17

How should pharmacotherapy be approached in fibromyalgia?

Answer 17

Individualized treatment tailored to the patient’s symptoms

Question 18

Which class of medications is commonly used in fibromyalgia management?

Answer 18

Antidepressants

Question 19

Which antidepressant classes have been used to treat fibromyalgia?

Answer 19

TCAs
SSRIs
SNRIs

Question 20

How does low dose Amitriptyline help in fibromyalgia?

Answer 20

Improves sleep
Reduces pain and fatigue

Question 21

What benefits does gabapentin provide in fibromyalgia?

Answer 21

May improve pain scores & sleep

Question 22

Which gabapentinoid is approved for use in adults with fibromyalgia?

Answer 22

Pregabalin

Question 23

What benefits are associated with pregabalin in fibromyalgia?

Answer 23

Pain relief with improvement in QoL, sleep & function

Question 24

How should pregabalin be initiated in fibromyalgia?

Answer 24

Start low and titrate slowly upward

Question 25

What is the recommended starting dose of pregabalin in fibromyalgia?

Answer 25

25-50 mg

Question 26

Why should pregabalin be titrated slowly in fibromyalgia patients?

Answer 26

To minimize adverse effects

Question 27

What are the common adverse effects of pregabalin?

Answer 27

Drowsiness & dizziness

Question 28

What is the role of insomnia medications in fibromyalgia management?

Answer 28

May benefit patients with severe sleep dysfunction but do not effectively reduce pain

Question 29

Which sedating antidepressants are commonly used to improve sleep in fibromyalgia?

Answer 29

Amitriptyline Trazodone

Question 30

What evidence supports the use of nabilone in fibromyalgia?

Answer 30

No evidence to suppport its use in the treatment of fibromyalgia

Question 31

What is the role of cannabis in fibromyalgia management?

Answer 31

Despite lack of evidence, some patients may choose to try medical cannabis for symptom management

Question 32

What is the role of cyclobenzaprine in fibromyalgia management?

Answer 32

Cyclobenzaprine - a muscle relaxant structurally similar to TCAs, is somewhat effective - particularly for improving sleep

Question 33

What is the role of opioid analgesics in fibromyalgia management?

Answer 33

No good evidence that opioids are effective; several guidelines recommend against their use due to risks such as opioid-induced hyperalgesia in patients with central sensitization.

Question 34

What is the role & mechanism of tramadol in fibromyalgia?

Answer 34

Tramadol (+/- acetaminophen) may reduce pain & improve health related quality of life, likely due to serotonin & norepinephrine reuptake inhibition rather than opioid effects

Question 35

When should tramadol be considered in fibromyalgia, and what is the concern?

Answer 35

Only if alternative therapies are ineffective or not tolerated; use requires careful assessment due to high risk of addiction/dependence.

Question 36

What is the role of NSAIDs in fibromyalgia pain management?

Answer 36

NSAIDs are not recommended for treating fibromyalgia pain.

Question 37

Why are NSAIDs ineffective in fibromyalgia?

Answer 37

They increase adverse effects without providing meaningful pain reduction.

Question 38

When may NSAIDs be used in patients with fibromyalgia?

Answer 38

Only for concurrent conditions, at the lowest effective dose for the shortest possible duration.

Question 39

What pain management approaches are recommended for fibromyalgia during pregnancy?

Answer 39

Nonpharmacologic approaches to pain control, stress management & energy conservation are preferred; Acetaminophen is the analgesic of choice due to safety in pregnancy.

Question 40

Which medications are NOT recommended or should be used with caution for fibromyalgia during pregnancy, and why?

Answer 40

NSAIDs: Avoid for fibromyalgia pain; short-term use may be considered in 1st–2nd trimester for concurrent conditions, but avoid in 3rd trimester due to antiprostaglandin effects → fetal/maternal bleeding, premature ductus arteriosus closure, and interference with labour onset or duration Tramadol: Not advised due to risk of neonatal withdrawal with long-term use Gabapentin / Pregabalin: Limited evidence; gabapentin not linked to major malformations but associated with low birth weight and preterm birth → use not recommended

Question 41

Which antidepressants may be continued in pregnancy for patients with fibromyalgia and depression, and why?

Answer 41

TCAs (e.g., amitriptyline): Appear relatively safe in pregnancy SNRIs (e.g., duloxetine): No increased risk of congenital malformations, but may cause neonatal agitation, jitteriness, and poor feeding; risk–benefit assessment required

Question 42

Which medications for fibromyalgia are considered compatible with breastfeeding, and why?

Answer 42

Acetaminophen: Safe; minimal transfer into breast milk Ibuprofen: Safe; minimal transfer into breast milk

Question 43

Which fibromyalgia medications are not recommended during breastfeeding, and why?

Answer 43

Tramadol: Not recommended due to risk of neonatal sedation and dependence Gabapentin/Pregabalin: Limited data; use only if necessary and with careful monitoring; alternatives with more evidence of safety preferred Tricyclic antidepressants (e.g., amitriptyline): May cause sedation in the newborn SSRIs (e.g., fluoxetine): Usually safe, but can cause poor weight gain, irritability, colic, vomiting, diarrhea, decreased sleep in some infants SNRIs (e.g., duloxetine): Effects on infants are unknown; caution advised

Question 44

How can fibromyalgia complicate the treatment of other medical conditions?

Answer 44

Fibromyalgia can complicate treatment of conditions like arthritis, hypothyroidism, and peripheral neuropathy, as symptoms may overlap or interfere with therapy.

Question 45

Which comorbid conditions are patients with fibromyalgia more likely to have?

Answer 45

Depression, irritable bowel syndrome (IBS), and low back pain.

Question 46

How should pharmacologic therapy be used in fibromyalgia?

Answer 46

In conjunction with nonpharmacologic modalities as part of a multidisciplinary treatment program.

Question 47

What outcomes should be documented when treating fibromyalgia?

Answer 47

Both reduced pain and improved function.