A 38-year-old woman comes to the office for chronic aching pain and stiffness all over her body for the last 6 months. Her symptoms are worse with exercise. She also has experienced fatigue, headaches, and insomnia. The patient tried water aerobic exercise 3 times a week but had no symptom improvement. She has a history of irritable bowel syndrome.
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/_Vital signs are within normal limits. Examination shows multiple tender spots over bony prominences. Her muscle strength is 5/5 in all extremities and deep-tendon reflexes are normal throughout. No sensory abnormalities are noted. There is no joint redness or swelling.
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/_Laboratory results are as follows:

Which of the following is the most appropriate therapy for this patient?

Question

A 38-year-old woman comes to the office for chronic aching pain and stiffness all over her body for the last 6 months.  Her symptoms are worse with exercise.  She also has experienced fatigue, headaches, and insomnia.  The patient tried water aerobic exercise 3 times a week but had no symptom improvement.  She has a history of irritable bowel syndrome. 
/_
/_Vital signs are within normal limits.  Examination shows multiple tender spots over bony prominences.  Her muscle strength is 5/5 in all extremities and deep-tendon reflexes are normal throughout.  No sensory abnormalities are noted.  There is no joint redness or swelling. 
/_
/_Laboratory results are as follows:

Which of the following is the most appropriate therapy for this patient?

Quizplus · Accepted Answer

This patient's clinical features are consistent with fibromyalgia (FM). FM presents most commonly in young- to-middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Initial FM treatment involves a multidisciplinary approach that includes patient education, regular aerobic exercise, and good sleep hygiene. Patients who do not respond to conservative measures may require medications. Tricyclic antidepressants (eg, amitriptyline) are preferred first-line drugs. Pregabalin, duloxetine, and milnacipran are alternate therapies approved for use in FM and can be useful for patients not responding to tricyclic antidepressants. Selection of the therapeutic agent should be tailored based on the patient's symptoms and the drug's side effect profile. Patients with persistent symptoms may require combination drug therapy, referral for supervised rehabilitation, pain management referral, or cognitive behavioral therapy. (Choice B) Pregabalin and gabapentin are anticonvulsant medications that have demonstrated effectiveness in FM. However, other anticonvulsants, including carbamazepine, are not known to be beneficial. (Choices C and D) Colchicine is used for treating gout, which typically presents with acute-onset monoarthritis. Methotrexate can effectively treat inflammatory arthritides (eg, rheumatoid arthritis, psoriatic arthritis), which are usually associated with elevated inflammatory markers (eg, erythrocyte sedimentation rate, rheumatoid factor) and joint pain. However, neither drug is effective for fibromyalgia. (Choice E) Opioids (eg, oxycodone), with the exception of tramadol, are usually not recommended for fibromyalgia as there is little evidence that they provide significant relief, and the risks (abuse) outweigh the benefits. Educational objective: Fibromyalgia causes fatigue, widespread pain, and cognitive/mood disturbances without other physical or laboratory abnormalities. Tricyclic antidepressants are an effective initial therapy. Pregabalin, duloxetine, and milnacipran can be effective for patients not responding to tricyclic antidepressants. __________ References: The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. (http://www.ncbi.nlm.nih.gov/pubmed/20461783) Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran in fibromyalgia syndrome: a systematic review with meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21078630) The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22452526)

A 38-Year-Old Woman Comes to the Office for Chronic Aching