Oh, My Aching Body: Tackling Fibromyalgia

17 Pages·2015·0.98 MB·English

Oh My Aching Body: Tackling Fibromyalgia

ACTIVITY DESCRIPTION ACCREDITATION
Fibromyalgia dramatically impacts the lives of those affected. This program Pharmacy
provides an overview of the currently theorized pathophysiology of this chronic
pain syndrome along with data on the effectiveness of nonpharmacologic, PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy
prescription and alternative treatments. Pharmacists can better counsel patients on Education as a provider of continuing pharmacy education.
treatment options after attending this program.
Nursing
TARGET AUDIENCE PharmCon, Inc. is approved by the California Board of Registered Nursing (Provider
The target audience for this activity is pharmacists, pharmacy technicians, and Number CEP 13649) and the Florida Board of Nursing (Provider Number 50-3515).
nurses in hospital, community, and retail pharmacy settings. Activities approved by the CA BRN and the FL BN are accepted by most State
Boards of Nursing.
LEARNING OBJECTIVES
After completing this activity, the pharmacist will be able to: CE hours provided by PharmCon, Inc. meet the ANCC criteria for formally approved
 Identify clinical features suggestive of fibromyalgia continuing education hours. The ACPE is listed by the AANP as an acceptable,
 Describe the role of disordered sensory processing and neural plasticity in accredited continuing education organization for applicants seeking renewal through
this syndrome continuing education credit. For additional information, please visit:
 Describe nonpharmacologic, prescription, and alternative treatments for http://www.nursecredentialing.org/RenewalRequirements.aspx
fibromyalgia
Universal Activity No.: 0798-0000-15-047-H01-P
After completing this activity, the pharmacy technicians will be able to: Credits: 1.0 contact hour (0.1 CEU)
 List signs and symptoms of fibromyalgia
 List medications used to help treat fibromyalgia Release Date: 12/29/2015
freeCE Expiration Date: 12/29/2017
ACPE Expiration Date: 06/29/2018

ACTIVITY TYPE
Knowledge-Based Live Webinar

FINANCIAL SUPPORT BY
PharmCon, Inc.
Geneva Briggs, PharmD, BCPS
President, Briggs and Associates

ABOUT THE AUTHOR FACULTY DISCLOSURE
Dr. Geneva Clark Briggs, a board-certified Pharmacotherapy Specialist, received It is the policy of PharmCon, Inc. to require the disclosure of the existence of any
her Doctor of Pharmacy and Bachelor of Science in Pharmacy degree from Virginia significant financial interest or any other relationship a faculty member or a sponsor
Commonwealth University, Medical College of Virginia. Additionally, she is the has with the manufacturer of any commercial product(s) and/or service(s)
owner of Briggs and Associates. Dr. Briggs was the Chief of Pharmacotherapy at discussed in an educational activity. Geneva Briggs reports no actual or potential
McGuire Veterans Affairs Medical Center and was an Assistant Clinical Professor of conflict of interest in relation to this activity.
Pharmacy and Pharmaceutics at Virginia Commonwealth University, Medical
College of Virginia. Prior to becoming Chief of Pharmacotherapy, she was a clinical Peer review of the material in this CE activity was conducted to assess and resolve
pharmacy specialist in geriatrics. After she left the Veterans Administration, she potential conflict of interest. Reviewers unanimously found that the activity is fair
worked for MedOutcomes, Inc training pharmacists to provide clinical services in balanced and lacks commercial bias.
community pharmacies. She has authored numerous articles and textbook
chapters. She currently speaks around the country on various topics, and develops Please Note: PharmCon, Inc. does not view the existence of relationships as an implication of
continuing education products. bias or that the value of the material is decreased. The content of the activity was planned to
be balanced and objective. Occasionally, faculty may express opinions that represent their
own viewpoint. Participants have an implied responsibility to use the newly acquired
information to enhance patient outcomes and their own professional development. The
information presented in this activity is not intended as a substitute for the participant’s own
research, or for the participant’s own professional judgement or advice for a specific problem
or situation. Conclusions drawn by participants should be derived from objective analysis of
scientific data presented from this activity and other unrelated sources.

Neither freeCE/PharmCon nor any content provider intends to or should be considered to be
rendering medical, pharmaceutical, or other professional advice. While freeCE/PharmCon and
its content providers have exercised care in providing information, no guarantee of it’s
accuracy, timeliness or applicability can be or is made. You assume all risks and
responsibilities with respect to any decisions or advice made or given as a result of the use of
the content of this activity.
Oh, My Aching Body:
Oh, My Aching Body: Tackling Fibromyalgia
Tackling Fibromyalgia
Activity UniversalActivity Number Activity Faculty
ACCREDITATION 0798-0000-15-047-L01 INSTRUCTION
C1.0re cdointstact hour(s) GOewnneevra, BBrriiggggss ,a Pnhda ArmssDoc, iBaCtePsS
FacultyDisclosure
Dr. Briggs has no actual or potential conflicts of interest in relation to this activity.
Learning Identify clinical features suggestive of Fibromyalgia
OBJECTIVES Describe the role of disordered sensory processing and neural plasticity in this syndrome
Describe non-pharmacologic, prescription, and alternative treatments for fibromyalgia
Legal The material presented here doesnot necessarily reflect the views of PharmCon, Inc. or the companies that support educational programming. A qualified
DISCLAIMER healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before
treating patients or employing any therapies described in this educational activity.
FACULTY:Geneva Briggs, PharmD, BCPS 12/29/2015 2
Clinical Features of FM
Outline
SLEEP DISTURBANCES
WIDESPREAD PAIN •Characterized by nonrestorative
•What is fibromyalgia? •• CtPhahetri oednnetifc idn, ewinsigdc refiepsaptotruersra eod of p fp aFaiMnin i s •sAolfeb senlpeo erampn daaln iitndiec ssr leienae stpeh dae r accwohniatetkiecntnuuiinrtyeg s
include: aching, exhausting, •Reduced slow-wave sleep
•What is thought to cause fibromyalgia related pain and other nagging, and hurting •Abnormal alpha wave intrusion
in non-REM sleep
symptoms?
•role of disordered sensory processing and neural plasticity
Cognitive & Memory
•How is it treated? Impairment
•Fibro fog
•Nonpharmacologic
•Prescription therapies FATIGUE/STIFFNESS
•Morning stiffness and fatigue
•Alternative medications TENDERNESS are common characteristics of
•Presence of tender points FM
•Most patients also have
tenderness to pressure
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Overlap Between Fibromyalgia and Related
Medical and Psychiatric Comorbidities with FM
Syndromes
Fib2r-o8m%y oafl gpiaopulation 1% of population Medical Disorder Prev(%ale)nce Psychiatric Disorder PrevLaifleetnimcee (%)
Dpaeifnin aendd b tye nwdideernspersesad Fatigue and 4 of 8 “minor criteria” Chronic fatigue syndrome 21-80 Major mood disorder 73.1
RSyengdioronmal ePsain “Sleep” Disorders Irritable bowel syndrome 32-80 Major depressive disorder 62.0
inIPTDrteareimisitrnoaspftbruidrtlloie aeb mlrB l acoaydnwsddteieitlbir s/u lar SSyCennedsnrittoirvamiltye RPSeleePrseistoplyed cs(ihsPc LiLLaMeimtgrSi b)cS yMDniodsvrooermmdeee nr(stRsL iSn) TdThMeeeisumnaolsdtpriiodpaoneclreh ro& cem hmaenmigdriicabaiunl lesae r nsitivities 31037--58305 AnBPxiaiepntoyicl ad dris idsooirsdrodererdrer 521581...167
Tension headache Major Depression PTSD 21.3
Vulvodynia OCD Interstitial cystitis 13-21 Social phobia 19.4
RhReAu/OmAatologic Disorders APTnSxDiety Chronic pelvic pain 18 OCD 6.5
Autoimmune diseases
Pain Physician: 2011; 14:E217-E245 Mayo Clinic Proc. 2015;90(5):680-692. Best PractROeCs DC=linobRsheesusimvea-tcool.m 2p0u0l3si;v17e: 5d6is3o-r5d7e4r. . PJ TCSlDin=Ppsoyscthtiraaturym. a2t0ic0 6st;6re7s:1s2 d19is-o1r2d2e5r..
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Who Gets Fibromyalgia? Impact of FM
•Significant impact on Quality of Life
•2-8% of population
•Negative impact in multiple aspects of QOL scales
•80-90% are females
•More impact than rheumatoid arthritis, osteoarthritis, osteoporosis, lupus
•All ages but peak 40-60 •Economic impact
•Some ethnic groups may have higher risk but conflicting data •Median annual costs $10,216 (mild) -$42,456 (severe)
•Indirect costs account for the 50-78% and involve losses in productivity,
reduced work hours, absenteeism, disability, unemployment, & early
retirement
Arthritis Rheum. 2008;58(1):26-35. Mayo ClinProc. 2015 ;90(5):680-692. J ManagCare Pharm. 2012;18(6):415-26. Pharmacoeconomics. 2014;32(5):457-66.
JAMA. 2014 ;311(15):1547-55 IntJ ClinPract. 2008;62(1):115-26
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Fibromyalgia Pathogenesis of FM and
ACR Diagnostic Criteria
Related Conditions
• Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6
•Genetics
and SS scale score ≥9.
• Symptoms have been present at a similar level for at least 3 months. •“Triggers”
• The patient does not have a disorder that would otherwise explain the pain •Mechanisms
•Relationship between physiological and psychological factors
SS Scale –Fatigue, waking unrefreshed, cognitive symptoms •Disordered sensory processing
• “Sensory Amplification Syndrome”
•Autonomic/neuroendocrine dysfunction
ExpertA Rrethvr iNtise uCraorteh eRre. s2 2001510;1;56(26()5:6):6670-06-7190.. Dis Mon. 2015;61(3):66-111
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Genetic Factors in FM “Stressors” Associated with FM and Related
Illnesses
•Candidate genes include serotonin transporter gene and COMT
•Peripheral pain syndromes •Psychological stress/distress
(catecholamine o-methyl transferase)
•Infections (eg, parvovirus, EBV, •Hormonal alterations
•COMT was predictor of developing TMD Lyme disease, Q fever, hepatitis) (eg, hypothyroidism)
•Pain sensitivity •Physical trauma •Certain catastrophic events (war)
•Genetic polymorphisms (automobile accidents)
•Similar pain disorder •Physical and sexual abuse
>8 Odds Ratio for
First-Degree Relatives to
Develop Fibromyalgia
Arthritis Rheum. 2004;50H(3u)m:94 M4-o9l5G2e. nPeati.n 2. 0200514;1 4;1(51)5:1(365):-1110423.. J Rheumatol. 2014 ;41(9):1737-45. Arthritis Care Res. 2011;63(6):808-20.
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Fibromyalgia Pathophysiology
The Role of Plasticity in Chronic Pain
Injury
Facilitation Inhibition
Acute Pain Ascending pathways Descending
Substance P Antinociceptive
Glutamate and pathways
EAAs Norepinephrine and
Normal Healing Healing With Plasticity NGF serotonin
(5-HT )
1a,b
Opioids
Pain Relief Hyperalgesia Allodynia
Chronic Pain 5-HT=serotonin. EAA=excitatory amino acid. NGF=nerve growth factor.
Marcus DM. Am FamPhysician. 2000;61:1331-1338. J Neurosci. 2007;27:10000-10006; ProgNeurobiol. 2002;66:355-474; Arthritis Rheum. 1992;35:550-556; Arthritis Rheum. 1994;37:1593-1601;Pain. 2007;8:737-745.
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From Mechanism to Treatment
Poll Question
•Treatments aimed at the periphery (ie, drugs, injections) are not very
efficacious
•Subgroups of patients with FM need different treatments •Which of the following is a common symptom of
•Drugs that raise norepinephrine and serotonin, or lower levels of excitatory fibromyalgia?
neurotransmitters, will be efficacious in some patients
•Hypotension
•Exercise, “sleep hygiene,” and other behavioral interventions are effective •Fatigue
therapies for biological reasons
•Fever
•Cognitive therapies are effective in FM and have a •Inflammation
biological substrate
Ann Intern Med. 2007;146:726-7B3e4s.t PPraainc tPRheyss iCcilainn.R 2h0e1u1m Maator-l.A 2p0r;0134;(127)::6E82517--74051..
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Dually Focused Treatment
Nonpharmacological Therapies
Symptoms of pain, fatigue, etc Strong Evidence Weak Evidence
• Nociceptive processes Pharmacologic therapies to • Education • Chiropractic, manual, and massage therapy
• Neuroendocrine and sleep dysfunction improve symptoms • Aerobic exercise • Acupuncture, electrotherapy, ultrasound
• Disordered sensory processing
• Cognitive-behavioral therapy (CBT) • Trigger/tender point injections
Modest Evidence
Functional consequences of symptoms • Strength training
• Increased distress
• Hypnotherapy, biofeedback, balneotherapy
• Decreased activity Nonpharmacologictherapies
• Isolation to address dysfunction • Tai-chi, yoga, qigong
• Poor sleep
• Maladaptive illness behaviors
Best Pract Res Clin Rheumatol. 2003;17:685-701. JAMA. 2004;292(19):2388-2395 CCoocchhrraannee DDaattaabbaassee SSyysst tRReevv. .2 2001135 ; 5;4:C:CDD000071097800.
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Patient Education Exercise
The Most Important Treatment for FM
•Validate pain •Aerobic exercise is nearly universally beneficial
•Explain disease
•Tolerance, compliance, adherence are biggest issues
•Realistic expectations
•Goal is not to be pain free but to have reduced/manageable pain •To maximize benefits
•Patient responsibilities •Begin gradually after pharmacologic therapy
•Begin with stretching, low-impact exercises; avoid strength training until
later
•Goal is to achieve regular, consistent physical activity
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Cognitive-Behavioral Therapy
•A program designed to teach patients techniques to
•Reduce their symptoms
Pharmacologic Approaches
•Increase coping strategies
•Identify and eliminate maladaptive illness behaviors
•Shown to be effective for most chronic pain syndromes
• In FM, small incremental benefit over control interventions in reducing
pain, negative mood and disability at the end of treatment and at long-
term follow-up
Cochrane Database SystRev. 2013 ;9:CD009796
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Pain Medication Usage Patterns
Pharmacologic Management of
Neuropathic Pain
45
FM patients Non-FM patients
40
BRAIN
35
DNOEpe/isoSceider onretdocnienipngto Irnshibition TSSTOrCSNapRARmioIssIsaiddsol stneitaP fo %12235050
Central Sensitization Peripheral Sensitization 10
SPINAL
Calcium Channels -Gabapentin, CORD Sodium Channels - 5
pregabalin, lamotrigine TCAs, carbamazepine, oxcarbamazepine, 0
phenytoin, lamotrigine, lidocaine, mexiletine Antiepileptics BZD NSAIDs Mus Relax Sedatives Opioids Antidepres Migraine
BZD, Benzodiazepines; NSAID=nonsteroidal anti-inflammatoIrnyt dJ rCulgin; PMruasctr. e2l0ax0,7 m;6u1(s9c)l:e14 r9e8la-x15a0n8ts.
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Relative Activity on Serotonin and Norepinephrine Reuptake Duloxetine (Cymbalta®)
Serotonin Mixed
Norepinephrine
•FDA-approved for FM
•An SNRI
Citalopram Venlafaxine Amitriptyline Maprotiline
•Start at 30 mg/d and up-titrate to 60 mg once daily
Fluvoxamine Duloxetine Milnacipran Desipramine
•Common side effects: nausea, headache, dry mouth, dizziness,
Sertraline Imipramine Nortriptyline somnolence, constipation, and fatigue
Paroxetine Reboxetine
Fluoxetine
Antidepressant Analgesic Antidepressant
Pain Med. 2000;1(4):310-316. Mayo ClinProc. 2012 ; 87(5): 488–496.Cochrane Database Syst Rev. 2013;1:CD010292
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Milnacipran (Savella®) Pregabalin (Lyrica®)
• First FDA-approved medication for FM
• Binds to the alpha2-delta site of voltage-gated calcium channels in the CNS
•FDA-approved for FM
• Start at 75 mg BID and up-titrate to 300-450 mg/d (150-225 mg twice a day)
•An SNRI (norepinephrine reuptake inhibition predominates)
• Side effects: dizziness, somnolence, headache, dry mouth, constipation, blurred
•Start at 12.5 mg/d and up-titrate to 50 mg twice a day vision, weight gain, and difficulty with concentration/attention
•Side effects: constipation, hot flush, hyperhidrosis, vomiting, palpitations, dry
mouth, and hypertension
Mayo ClinProc. 2012 ; 87(5): 488–496.Cochrane Database Syst Rev. 2013;1:CD010292 Mayo ClinProc. 2012 ; 87(5): 488–496.Cochrane Database Syst Rev. 2013;1:CD010292
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