A 38-year-old woman comes to the office because of chronic aching pain and stiffness around her neck, shoulders, lower back, and hips. Even minor exertion worsens the pain. The patient also has difficulty sleeping and frequently wakes up in the middle of the night. Even after a good night's sleep, she always feels fatigued in the morning. The patient has no muscle weakness, fever, malaise, weight loss, or rash. She 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 at muscle insertion points and bony prominences. Her muscle strength is 5/5 in all extremities, and deep-tendon reflexes are 2+ throughout. No sensory abnormalities are noted. 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 because of chronic aching pain and stiffness around her neck, shoulders, lower back, and hips.  Even minor exertion worsens the pain.  The patient also has difficulty sleeping and frequently wakes up in the middle of the night.  Even after a good night's sleep, she always feels fatigued in the morning.  The patient has no muscle weakness, fever, malaise, weight loss, or rash.  She 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 at muscle insertion points and bony prominences.  Her muscle strength is 5/5 in all extremities, and deep-tendon reflexes are 2+ throughout.  No sensory abnormalities are noted.  Laboratory results are as follows:  Which of the following is the most appropriate therapy for this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with likely fibromyalgia (FM). FM presents most commonly in young to middle-age women with widespread pain, fatigue, and cognitive/mood disturbances. Patients tend to have fairly normal physical examination findings except for point tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. FM has no specific diagnostic laboratory findings. Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale rather than trigger points for FM diagnosis. The index and severity scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms. widespread pain index and symptom severity scale Initial FM treatment should emphasize 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. Serotonin and norepinephrine reuptake inhibitors (eg, duloxetine, milnacipran) and pregabalin are alternate therapies that may be useful for patients not responding to tricyclic antidepressants. Patients with persistent symptoms may require combination drug therapy, referral for supervised rehabilitation, pain management consultation, or cognitive-behavioral therapy. (Choices B and C) Colchicine is used to treat 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 [ESR], rheumatoid factor) and joint pain. However, neither drug is effective for FM. (Choices D and F) Glucocorticoids (eg, prednisone) and nonsteroidal anti-inflammatory drugs (eg, naproxen) can treat inflammatory conditions that typically have elevated markers (eg, ESR, C-reactive protein). However, FM is not an inflammatory condition and does not usually respond to glucocorticoids or nonsteroidal anti-inflammatory drugs. (Choice E) Opioids (eg, oxycodone), except for tramadol, are usually not recommended for FM as there is little evidence that they provide significant relief, and the risks (eg, abuse, diversion) outweigh the benefits. Educational objective: Fibromyalgia is a pain syndrome that occurs most commonly in young to middle-aged women and is characterized by fatigue, widespread pain, and cognitive/mood disturbances. Amitriptyline is an effective initial therapy. Pregabalin, duloxetine, and milnacipran are alternate therapies 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 Because of Chronic