Page 31 - World of Irish Nursing April 2018

50 Focus

Primary healthcare professionals have the Figure 1: Management of fibromyalgia
best knowledge of our patients from the (EULAR guidelines 2016) 8
biopsychosocial perspective as well as pro-
viding primary care over a prolonged period History and physical examination
of time and it would only seem right that
the primary care setting should be the focal Diagnosis of fibromyalgia
point of management. an early and positive If needed to exclude treatable
diagnosis could reduce costs by avoiding Patient education and information sheet comorbidities:
unnecessary testing, imaging, medication if insufficient effect • Laboratory and/or radiological
use, specialist referrals and primary care visits. Physical therapy with individualised graded physical exercise (can exams
The diagnosis of fibromyalgia is based be combined with other recommended non-pharmacological • Referral to other specialties
mostly on the clinical evaluation and with therapies such as hydrotherapy, acupuncture)
simple blood tests. although testing for the if insufficient effect
typical 18 sites for tenderness as specified Reassessment of patient to tailor individualised treatment
by the aCr is helpful, it should not be used
to confirm the diagnosis as the examination Additional individualised treatment
alone is mainly a subjective technique. it is Pain-related depression, Severe pain/sleep disturbance Severe disability/sick leave
reported that 25% of patients diagnosed with anxiety, catastrophising, overly
fibromyalgia do not have 11 tender points .7 passive or active coping
However, asking the patient about the
associated symptoms including non-restor- Psychological therapies Pharmacotherapy Multimodal rehabilitation
ative sleep, poor concentration and fatigue Mainly CBT Severe pain programmes
in the setting of chronic widespread pain • For more severe depression/ • Duloxetine
strongly suggests a diagnosis of fibromyalgia. anxiety, consider psycho- • Pregabalin
pharmacological treatment
only simple blood tests like FbC, U&E, • Tramadol (or in combination
with paracetamol)
TFTs (to rule out hypothyroidism), ESr, Severe sleep disturbance
CrP, a comprehensive metabolic panel, and • Low-dose amitriptyline
fasting glucose test are needed. Vitamin • Cyclobenzaprine or
D levels could also be taken because vitamin • Pregabalin at night
D deficiency can aggravate pain, although it
doesn’t cause it. antibodies such as aNa, (or both if they are present). Psychological with increased sensitivity to alcohol.
9
rF and anti-CCP may be requested if the therapies are included in updated guide- Sleep hygiene is imperative, as patients
examination suggests an autoimmune cause. lines and include education an cognitive with disturbed sleep patterns and lifestyle
Specialist consultation should be sought if behavioural therapy (CbT). 8, 9 changes often experience increased fatigue,
symptoms suggest an alternative diagnosis. Non-pharmacological: which might result in non-compliance. Care
Management and treatment • Active therapy including aerobic exercise should be taken with prescribing medica-
There is no cure for fibromyalgia and (20 min/day, two to three times a week) tions such as opiates and neuroleptics due
treatment should aim towards reducing • Passive therapy including balneotherapy to their addictive nature.
symptoms and a goal of the patient reaching (heated spa or pool treatment), massage, Declan Brennan is a general practitioner in Mullingar;
optimal function in daily life. management manipulation Peter Polydoropoulos is a psychiatry registrar at St Loman’s
of symptoms should take into consideration Psychological: Hospital, Mullingar and Patrick Murphy is a consultant
the fluctuating and heterogenous nature of • Education to explain symptoms and physician at the Midland Regional Hospital, Tullamore
symptoms in a multimodal, patient-tailored mechanisms of fibromyalgia References
1. Fitzcharles M, et al. 2012 Canadian Guidelines for the
approach. Educating the patient is helpful • CBT to reduce pain with focus on what Diagnosis and Management of Fibromyalgia Syndrome:
1
since diagnosis and an explanation for their links pain, thought (mood) and behaviour Executive Summary. Pain Research and Management.
symptoms should reassure the patient that (negative coping strategies). 2013;18(3):119-126.
2. Okifuji A, et al. Management of fibromyalgia syndrome
they do not have a more severe illness. 1 Pharmacological: in 2016. Pain Management. 2016;6(4):383-400.
This would hopefully reduce the need for • Anti-depressant: amitriptyline 10-50mg 3. Giusti E, Castelnuovo G, Molinari E. Differences in
Multidisciplinary and Interdisciplinary Treatment
unnecessary investigations. 7 • Anti-convulsant: pregabalin 300-600mg Programs for Fibromyalgia: A Mapping Review. Pain
recent EUlar guidelines recommend • Serotonin-norepinephrine re-uptake Research and Management. 2017;2017:1-19.
focusing on pain, fatigue, sleep and daily inhibitor: duloxetine 60-120mg 4. Goldenberg D. Management of Fibromyalgia
Syndrome. JAMA. 2004;292(19):2388.
functioning. These recommendations are evi- • Tramadol and paracetamol combination: 5. Arnold L, Clauw D. Challenges of implementing
dence-based, can be tailored to the individual Tramadol 37.5mg/325mg paracetamol fibromyalgia treatment guidelines in current clinical
practice. Postgraduate Medicine. 2017;129(7):709-714.
patient and include both pharmacological
four times per day.
6. Fibromyalgia Criteria | National Data Bank for
WIN Vol 26 No 3 April 2018 gest a graduated approach, beginning with ing amitriptyline 7.5mg nocte titrating up to 2017 [cited 11 October 2017]. www.arthritis-research.org/
Rheumatic Diseases [Internet]. Arthritis-research.org.
Experience at a clinical level involves start-
and non-pharmacological therapies.
The EUlar guidelines in Figure 1 sug-
research/fibromyalgia-criteria
7. Rahman A, Underwood M, Carnes D. Fibromyalgia. BMJ.
50mg (if needed) per night optimal for pain
2014;348(feb24 5):g1224-g1224.
and sleep relief. Pregabalin can be started at
non-pharmacological therapies such as
8. Macfarlane G, et al. EULAR revised recommendations
exercise with an individualised pharmaco-
25mg, twice daily for pain and anxiety, titrat-
for the management of fibromyalgia. Annals of the
Rheumatic Diseases. 2016;76(2):318-328.
logical plan thereafter for the treatment
ing up as needed. Side-effects can be an
9. [Internet]. 2017 [cited 11 October 2017]. www.
of either severe pain or sleep disturbance
initial complaint with pregabalin, especially
nbmedical.com/pdf/KISS_Fibromyalgia.pdf