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September 21, 2007 — The European League Against Rheumatism (EULAR) has issued the first guidelines for the treatment of fibromyalgia syndrome (FMS) and published them in the September 17 Online First issue of the Annals of the Rheumatic Diseases.
"Although effective treatments are available no guidelines exist for management of FMS," write Serena F. Carville, from King's College London, United Kingdom, and colleagues. "The objectives were to ascertain the strength of the research evidence on effectiveness of treatment of FMS and develop recommendations for its management based on the best available evidence and expert opinion to inform healthcare professionals."
Of 146 studies eligible for review, 39 pharmacologic intervention studies and 59 nonpharmacologic studies were used to create the final recommendation summary tables, after those of lower quality or with insufficient data were excluded. Identified categories of treatment were antidepressants, analgesics and "other pharmacological," and exercise, cognitive behavioral therapy, education, dietary interventions, and "other nonpharmacological interventions."
Specific recommendations in these guidelines regarding general considerations for management of FMS are as follows:
Comprehensive evaluation of pain, function, and psychosocial context is needed to understand FMS completely, because it is a complex, heterogeneous condition involving abnormal pain processing and other secondary features (level of evidence, IV D).
Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of nonpharmacologic and pharmacologic interventions. After discussion with the patient, treatment modalities should be specifically tailored based on pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance (level of evidence, IV D).
Specific recommendations on nonpharmacologic management of FMS are as follows:
Heated pool treatment, with or without exercise, is effective (level of evidence, IIa B).
For some patients with FMS, individually tailored exercise programs can be helpful. These may include aerobic exercise and strength training (level of evidence, IIb C).
For certain patients with FMS, cognitive behavioral therapy may be beneficial (level of evidence,IV D).
Based on the specific needs of the patient, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated (level of evidence, IIb C).
Specific recommendations on pharmacologic management are as follows:
Tramadol is recommended for management of pain (level of evidence, Ib A). Although other treatment options may include simple analgesics (eg, paracetamol) and other weak opioids, corticosteroids and strong opioids are not recommended (level of evidence, IV D).
Antidepressants are recommended for the treatment of FMS because they decrease pain and often improve function (level of evidence, Ib A). Appropriate options may include amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole.
Tropisetron, pramipexole, and pregabalin are recommended for the treatment of FMS because they reduce pain (level of evidence, Ib A).
Limitations of these recommendations are that some are based only on expert opinion; basis from clinical trial data limited to changes in pain measured by the VAS and function evaluated with the FIQ; failure to consider positive effects on other outcome measures of pain or on function evaluated with different instruments; and high variability in outcome measures used, results reporting, and poor methodologic quality precluding meta-analysis.
Ann Rheum Dis. Published online September 17, 2007.
Clinical Context
The predominant rheumatologic features of FMS include chronic, widespread pain and lowered pain threshold, with hyperalgesia and allodynia. Other features often accompanying FMS include fatigue, depression, anxiety, sleep problems, headache or migraine, bowel irregularity, diffuse abdominal pain, and urinary frequency.
Of 146 eligible studies reviewed, those of lower quality or with insufficient data were excluded, and 39 pharmacologic and 59 nonpharmacologic studies were used to create the 9 final recommendations.
The 9 recommendations included 8 management categories, 3 of which had strong evidence from the current literature, and 3 that were based on expert opinion.
The 9 recommendations were as follows:
Comprehensive evaluation of pain, function, and psychosocial context are needed to understand FMS completely, because of its complex, heterogeneous nature.
Optimal treatment of FMS mandates a multidisciplinary approach, including nonpharmacologic and pharmacologic interventions. Treatments should be specifically tailored to patient reports of pain intensity, function, and associated features such as depression, fatigue, and sleep disturbance.
Heated pool treatment, with or without exercise, is effective. Individually tailored exercise programs, which may include aerobic exercise and strength training, may be helpful for some patients.
Cognitive behavioral therapy, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated for certain patients.
Tramadol is recommended for management of pain from FMS. Simple analgesics (eg, paracetamol) and other weak opioids may be considered, but corticosteroids and strong opioids are not recommended.
Antidepressants are recommended to decrease pain and improve function (eg, amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole).
Tropisetron, pramipexole, and pregabalin are recommended to reduce pain of FMS.
EULAR plans to update the guidelines every 5 years and incorporate findings from good-quality clinical trials that will add to currently available evidence.
Pearls for Practice
Pharmacologic interventions recommended for FMS include tramadol for pain management, with simple analgesics and weak opioids if needed. Corticosteroids and strong opioids are not recommended. Antidepressants are recommended to decrease pain and improve function.
Nonpharmacologic interventions recommended for FMS include comprehensive evaluation; multidisciplinary, specifically tailored therapy; and heated pool treatment, with or without exercise. Individually designed exercise programs, cognitive behavioral therapy, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be helpful for some patients.
Thought some DB members outside of US might appreciate this as they would be impacted by the guidelines. Color highlight are mine
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ok, don't flame me. what exactly is fibro?
the people who are fibromyalgic would be best to describe it to me, rather than wikipedia and other internet sources.
i am under the impression that it is almost an unbearable pain (be it in the abdomenal area or throughout the body.)
ok, the real reason i ask is that some days all i feel like doing is smoking and staying in bed to avoid the agony of movement.
i don't think that i suffer from this relatively new diagnosis, but i have never been able to find consistent information on this subject.
again, don't flame me--i am only looking for answers. did kcob suffer from fibro? it at least seems that the pain he talked about was indeed chronic and severe.
-bones
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Hi everyone. I have fibromyalgia. I've been suffering for 9 months. My doctor told me today that the 5/500 mg Lortab that I recieved for TWO months would not be refilled. He said that other people with fibro don't take narcotics to help the pain. I know this is a lie. He gave me topamax and upped my cymbalta.
Honestly, I have tried so hard not to take the pain pills even when I had them but the pain is just Soooo bad! I don't know what to do. Do I look for another doctor. Try to find alternate ways to get the medication I need? The 5/500 Lortab would barely take the edge off at times. What are people like me supposed to do?
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Anybody else have this symptom? Can't say I've ever had it before. Don't know if it's the fibro or something else. Just hoping to get some input. For women with children, the pain reminds me of being 8 or 9 months pregnant and the baby is pushing out on your ribs! Make sense? TIA!
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any ideas out there on what actually works for the severe fatigue that comes day after day?. i heard provigil would be really good,but no insurance will cover it,so no doctor will even prescribe it.anyone get prescribed phentermine? ive tried adderall,it made me twice as tired, and ritalin worked for awile,but makes me tired as well.any ideas??im not talking a little bit of fatigue,its severe,that days i feel like i just cant go on at all.i have a hyper son diagnosed with autistic/sprectrum disorder,so i have to keep up with him.
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"(1) Fibromyalgia is a set of symptoms and signs resulting from hypometabolism. (2) Most patients’ hypometabolism has multiple causes. (3) The most common and most potent cause of patients’ hypometabolism is too little thyroid hormone regulation, due either to hypothyroidism or partial cellular resistance to thyroid hormone."
T4 and T3 levels are directly linked to almost every aspect and symptom of fibro, overseas and even in the united states it is becoming more clear that hypothyroidism could be the culprit of fibromyalgia. symptoms of hypothyroidism are:
Note symptoms including: weight gain, depression, forgetfulness, fatigue, hoarseness, high cholesterol, constipation, feeling cold, hair loss, dry skin, low sex drive, tingling hands/feet, irregular periods, infertility.
Note related conditions, including: recurrent pregnancy loss, resistant high cholesterol, difficult menopause, fibromyalgia, chronic fatigue syndrome, carpal tunnel syndrome, mitral valve prolapse.
This is from many different studies and is fact.
My suggestion is to read the following links i post here and go see an endocrinologist to have your TSH T3 T4 Free T3 and Free T4 levels checked. some may come back looking fairly normal and in this case have him run a TRH stimulus test (Thyrotropin-releasing hormone), that is explained in this link: http://www.rain-tree.com/fibromyalgia.htm
also please trust me and read these links below to determine if you should look into hypothyroidism.
http://www.ei-resource.org/illness-information/related-conditions/thyroid-treatments/
http://www.drlowe.com/frf/england2002/brief.htm
i hope this helps.
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Thought this might be of some interest… Sorry for the long post.
Last week I made another fruitless attempt for relief at my 4th PS doctor. I’ll give a bit of background so this will make sense.
I asked my new GP if he knew of a Pain Specialist (PS) who knows something about Fibromyalgia (FM). It’s amazing what Dr.’s don’t bother to find out about this disease. I haven’t had a Rheumy yet ( 7 & counting) who half knew the symptoms and how serious this can be. GP sent me to Cambridge so I thought maybe I had a chance. I asked the secretary while making the appointment if they have FM patients there, “Oh yes, we have quite a few”. So I summoned up the courage and went for the hour ride.
I sit in the exam room in my stylish butt flash smock waiting for the doc. He comes in and looks like a high school kid (cute just the same). I asked if he was Dr. G & he stated he was the resident. Great. All that I have wrong with me and I get examined by an amateur. (Don’t jump on me for that. I know everyone has to learn but my days as a guinea pig are over. At least the Dr. I came to see should be in the room).
He starts asking questions and was very surprised to find I also had RA & 3 Herniated discs. GP didn’t think this was important I guess. He asked me what was wrong. I told him I literally hurt from neck to toe. Conversation as follows:
“Where does it hurt the most?”
“Hips, knees, feet, shoulders, hands, neck, etc, etc…”
“Ok, where does it hurt the most?”
“One day it will be my hips, next day I won’t be able to sleep on my side. Next day I won’t be able to stand the covers touching my feet. I’ll go for days when my SKIN hurts. Not that the other areas stop hurting, it’s just I’ll notice what hurts the most that day.”
“If we could make one area stop hurting TODAY, what would it be?”
At this point I’m aggravated. If he knew about FM he’d know what I was talking about. I felt like telling him to throw a dart & pick a spot himself. I knew all my hope was in vain at that point. I relented and just said “hips” with a heavy sigh. Then I knew exactly what he was going to say…
“Needles in the bursa sacks with plenty of numbing medication, blah, bla-blah, bla-blah…”
“And how does that help the rest of me?”
You know they never ask WHY you don’t want the injections. Anyway, he says “Ok, we’ll give you something to help you without the injections.”
“Is that possible?”
“Sure” he says enthusiastically as he exited the door…I wanted to say “Wanna make a bet?” sooo bad.
Here’s where it gets good.
I clearly hear him & the Dr. talking just outside the door. What caught my attention was when resident said “She WON’T tell me where it hurts the most…” I strongly disagreed with that so I strained to listen. It was broken up but I got the gist.
Res: “RA & Discs”
Dr.: “Insurance?”
Res: “State”
Dr.: Every Insurance Co….different….won’t pay for some (diseases?). Someone with…….they tell me it doesn’t exist……….so I might as well just stay home……
I missed a minute or two here then:
Dr.: “Surgeons are the worst. Insurance will tell them……they receive major kickbacks….It’s all run by insurance companys. The most corrupt is America and the U.K. The least corrupt is Sweden, Denmark…..
He went on for a few more minutes but I couldn’t hear anymore. I managed to jot down a few things that he said since I was still filling out paperwork. Wow.
He came in and immediately started filling out the notes to send back to my GP. He took a look at the list of meds that I have already tried for FM. To sum up the rest of the visit…
Dr.: “Well it looks like you’ve tried everything that I would prescribe you for FM. Those meds didn’t work or had side effects so the best I can tell you is to try light exercise…”
Me: “How am I supposed to do that when I can barely stand for 5 minutes…blah, bla-blah, bla-blah…”
Then I straight out asked (told) him:
“Listen, I was just hospitalized recently and when I was released they gave me Percocets. It took care of the pain pretty well but it made me very tired. Is there anything that strength that will not make me so tired so I can get some exercise? I think that’s 90% of my problem. I can’t do anything.”
Dr.: “No. Even the top FM organizations tell us not to treat it with opioids, they don’t work and it makes the pain worse after a while.” LIAR !!!!!!!!! * see below
Me: “Thank you for your time.” (translation - you are dismissed you peasant, money grubbing, sheep-hoe).
* When I got home I happened to find this from the NFA (National Fibro Assoc.) - “Fibromyalgia patients can be placed on chronic opioid analgesic therapy- This particular class of drugs effectively treats fibromyalgia syndrome”
Full article - http://www.fmaware.org/site/News2?page=NewsArticle&id=5307
AND I personally happen to KNOW it works BECAUSE I have personally experienced it.
Here’s one for ya Dr. ‘I know all because I think I’m GOD’ - you read about this stuff - I LIVE IT!!!! Don’t tell me it doesn’t work. This long post is proof. I know exactly what works for me.
Sorry, I digress, back to the subject at hand. This is such a kick in the teeth. I know that all this corruption goes on but it’s quite another thing to have the Dr your supposed to trust with your health come in and not help you because of politics. I’m fantasizing about writing him a letter telling him I heard what he said and he’s scum for letting me suffer. So not only do FM/CP’ers have to battle pain, but also insurance companys, DEA and Dr.’s who are sheep. Then they wonder why we go to the internet or our friendly neighborhood drug dealer.
I’m sorry for my long windedness, but my second to last post was more than a year ago. It’s not for lack of wanting to, it’s because I can’t do it without some “help” which nowadays is very scarce. I’ll stop before this becomes a book.
And the battle goes on…..
Brightest Blessings to All~
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I have shoulder surgery coming up. I want to know, for those of you that take oxycodone, which generic brand is the most effective for you? Or do you even notice a difference? I want to avoid a major flare, and of course any excessive pain due to the FM after the surgery. I'm taking Mallies in generic 5mg form right now. I only take 1 or 2. After surgery I will be allowed to take up to 4 (20mg) and I want the most effective. I know some people have a poor opinion of Mallies when it comes to hydrocodone, but I don't know much about the oxycodone. This is a new medication for me and I'm only taking it for my shoulder. Any opinions are appreciated. BTW, I find the Mallinkrodt offers good enough pain relief for now. But if you know of a better (stronger) generic (I know they can be 20% difference in either direction) I'd like to know. I want as much pain control as possible!
Thanks!
Tia
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I'm having shoulder surgery in less than 2 weeks. I'm already in a fair amount of FM pain and the shoulder is even worse. I'm wondering if you had a flare up afterwards. I'm also wondering how you handled your need for possibly more than the usual amount of pain relief. How did you bring this up with your surgeon? Did they think you were a quack? Were they skeptical?
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my ex-doc told me fibro does not even exist. he says it is a made-up "condition" used by women to get opiates. he was gleeful when they came out recently with lyrica, says it derails all the opiate-seekers using the fibro complaint. I wouldn't doubt he feels the same way about migraine sufferers. he even devised a 30-question sheet to ask migraine patients to determine if they really have migraines or are drug-seeking.
he has no problem rx'ing benzo's though. ask for a narcotic or just go in nervous, shaking and wring your hands - he couldn't rx benzo's fast enough, just wanted you out of there!
despite having all the classic symptoms, (dark urine, abnormal test, intense itching from bile backing up in the blood, yellow eyes) it took hom 3 months to finally order an mri that showed a cancerous growth on the pancreas was blocking her bile duct. at 87, she had to have the whipple procedure, the most invasive surgery there is other than a liver transplant.
also, every time I'd ask a question or he needed to rx a med, he had to mess around on the computer to find an answer.
and all this takes 10 minutes. if you need longer, the only thing you can do is block the door, stand in front of it till you are thru with your questions and concerns. then bills the ins co for $165!
are doc's all like this? I fired him obviously, but mom still goes to him. I feel like I really have to research all symptoms now and tell the doc what's wrong. shouldn't be that way.
luckily my sub doc is a regular doc - she's my pcp now. charges $98 for a once-a-month visit and spends the full hour chatting. you can get out all your questions out and get intelligent, unhurried answers. no computer in sight. almost like a welcome therapy session.
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