Fibromyalgia is a poorly understood condition, estimated to affect approximately 1.5-2 million people in the UK. (NRS Healthcare, 2019). The disease can affect any age, but is most commonly seen in those aged between 30-50 years old. Women are much more likely to develop the condition than men (Tidy, 2014). The illness places a huge burden on healthcare resources with high levels of prescribing, testing, referrals and visit rates in the three years leading up to the diagnosis (Hughes et al, 2005). The high number of referrals or diagnostic investigations may have been caused by clinicians struggling to find a cause for the patients worsening symptoms and frequent appointments. It is thought likely that the true prevalence rates may be much higher than statistics suggest because some sufferers with milder symptoms may self-medicate with over the counter preparations and never seek help, or because of the complex nature of the disease and its variable presentation, may be misdiagnosed. It is hoped that this article will give nurses and non-medical prescribers an overview of this illness and help them when advising and treating their patients.
Pathophysiology
The underlying processes remain unclear, but it is thought that alterations to sleep pattern and changes in neuroendocrine transmitters (such as serotonin, growth hormone and cortisol) indicate that regulation of the autonomic and neuroendocrine systems may be the underlying basis of the condition (Jahan et al, 2012). There are thought to be several mechanisms involved in unusual pain processing. A complex interaction of blunting the pain pathways and alterations in neurotransmitters may lead to the abnormal neurochemical processing of sensory signals in the central nervous system (Jahan et al, 2012). These processes are thought to cause amplification and disturbance to normal sensory signals resulting in a lowered pain threshold and unrelenting pain.
Signs and symptoms
Fibromyalgia is a potentially debilitating disease characterised by a multitude of symptoms, which make assessment by the clinician problematic and diagnosis challenging and extremely difficult. Pain at multiple sites is the most common complaint, which leads patients to consult their GP. Lower back pain with/without radiation to the buttocks and legs and pain in the neck and across the shoulders are common features (Tidy, 2014). Many of the additional symptoms may easily be attributed by clinicians to other conditions. Box 1 shows some of these.
Box 1.Additional symptoms of fibromyalgia
- Early morning stiffness
- Fatigue
- Poor sleep patterns, which may contribute to depression and worsen other symptoms
- Headaches
- Cognitive disturbance (problems with memory or finding the right words
- Abnormal skin sensations, such as tingling, pins and needles paraesthesia
- Feeling of swollen joints with no swelling present
- Weight fluctuations
- Dizziness and feeling light headed
Source: Tidy (2014)
Diagnosis
Making a diagnosis is extremely difficult for clinicians because of the likelihood patients may present with multiple symptoms. Choy et al (2010) reported that patients most commonly presented with a combination of pain, fatigue, sleeping problems and concentration difficulties. Patients in this study had waited, on average, almost a year after onset of symptoms before presenting to a physician, and then an average of 2.3 years, having seen between three and seven physicians before receiving a diagnosis of fibromyalgia (Choy et al, 2010). Many patients in this study reported finding it difficult to explain their symptoms, making the process of diagnosis even more difficult.
Table 1 gives a brief overview of diagnosis. Bloods may also be requested as part of the process to exclude any other cause for the patient's symptoms.
Table 1. Diagnosis(Chakrabarty and Zoorob, 2007)
| Symptoms | Additional information |
|---|---|
| Widespread pain, affecting both sides of the body | Present for at least three months and affecting the bones and joints above and the waist |
| Presence of tender points | There should be a minimum of 11 tender points at various sites across the body |
| Digital palpation | This should be done using the thumb to apply pressure which should be just enough to blanch the examiners thumbnail. This would not cause pain in someone without fibromyalgia |
Treatment and management
There is no specific treatment for fibromyalgia and no single drug that will target multiple symptoms. A holistic approach to treatment is needed and should focus on addressing all elements of symptomology (physical, social, psychological and personal needs), and may involve a combination of therapies (Lee et al, 2013). Offering a suitable treatment becomes even more difficult when the clinician is faced with several issues, which needs to be addressed. Non-pharmacological treatments are usually tried first, these will be covered later in the article as the focus of this paper is the pharmacological treatments
Medication is often deferred for use if other non-pharmacological options have been ineffective. Unfortunately, medication side effects are commonly exacerbated in this patient population and many drugs are tolerated poorly (Northcott et al, 2017). Patient choice will also impact on prescribing decisions and it makes sense to target the patients most troublesome symptoms.
Comorbidity
The underlying pathophysiology of fibromyalgia, and the widespread pain and stiffness that patients experience, are features shared with a number of other diseases where chronic pain is part of the clinical picture. Unfortunately, other functional pain syndromes have been found to be more common in patients with fibromyalgia (Kodner, 2015). Several have been cited including pelvic pain, dysmenorrhoea, low back pain, irritable bowel syndrome and interstitial cystitis, all of which are more frequently seen in fibromyalgia sufferers (Hawkins 2013), making clinical assessment and treatment of these patients extremely difficult. Mood disturbances and depression are also frequent features in the presence of chronic pain and are thought to share underlying triggers (Kodner, 2015).
Initial drug choices
Patient assessment and history taking will determine what the patient feels are the most troublesome and debilitating problems they are trying to cope with. Hauser et al (2014) suggests amitriptyline or pregabalin could be preferred for those with sleep disturbances, duloxetine for those with major depression, and duloxetine or pregabalin for those experiencing general anxiety disorder (discussed in detail below). Any treatment offered aims to minimise distressing symptoms and improve the patient's quality of life, and is likely to involve a combination of pharmacological and non-pharmacological treatments. Pharmacological treatments will follow (see Table 2 for drug side effects).
Pharmacological treatments
Amitriptyline
Tricyclic antidepressants, in particular amitriptyline, have been one of the most widely used treatments for fibromyalgia in recent years. Initiation is usually at a low dose and can be titrated upwards if well tolerated. Studies of amitriptyline have, however produced conflicting results, Dedhia and Bone (2009) reported that drugs of this type have been shown to improve muscle stiffness, tenderness, fatigue and sleep quality (Dedhia and Bone, 2009). In addition, when prescribed at doses of 25-50 mg given at bedtime, tricyclic antidepressants were effective in providing an analgesic effect as well as treating concomitant mood disorders (Chakrabarty and Zoorob, 2007). A Cochrane review was less positive, indicting that amitriptyline provides good pain relief in about one in four (25%) more people than placebo, but approximately one in three (31%) more people than with placebo reported having one or more adverse events, which although usually not serious but, may be troublesome enough to interfere with them continuing to take the treatment (Moore et al, 2015).
Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) (such as fluoxetine, sertraline, citalopram) are frequently prescribed for the management of depression in fibromyalgia, but there is doubt as to their effectiveness in treating the key symptoms of the disease, namely pain, fatigue and sleep problems. (Walitt et al, 2015). With this in mind, SSRIs are reserved for use if non-pharmacological options (such relaxation techniques, sleep hygiene and exercise) as have failed to produce significant benefit. Patients may therefore need additional drugs to help alleviate these symptoms if needed.
Selective norepinephrine serotonin reuptake inhibitors
Drugs of this type appear to be more effective in relieving fibromyalgia symptoms and duloxetine has been shown to reduce pain and improve the patient's overall sense of wellbeing (Hawkins, 2013). Studies comparing duloxetine to placebo in this condition have shown that it achieves a significant reduction in pain, but many could not tolerate a dose of more than 60 mg due to side effects (Table 3) (Northcott et al, 2017). A recent Cochrane review reported that although duloxetine had some impact on improving quality of life, little improvement in sleep patterns was seen and more people dropped out of the trial because of side effects than with placebo (Welsch et al, 2018).
Table 3. Drug side effects: BNF (2020)
| Table head | Common side effects | Rare side effects |
|---|---|---|
| Tricyclic antidepressants (such as Amitriptyline) |
|
|
| Selective serotonin reuptake inhibitors (SSRI'S) (such as fluoxetine) |
|
|
Anticonvulsants
Anti-epileptic drugs (such as gabapentin and pregabalin) appear to achieve an effect by inhibiting the release of pain pathway neurotransmitters. Mcfarlane et al (2005) found that pregabalin was effective in achieving as much as a 30% reduction in pain, but had a smaller effect on sleep and fatigue and no impact at all on disability. These findings were replicated in a Cochrane review, but side effects were common and resulted in a number of participants withdrawing from the study (Derry et al, 2016). A review of gabapentin for fibromyalgia found a similar 30% reduction in pain, a small effect on sleep. However, a recent Cochrane review concluded that there is currently insufficient evidence to recommend the routine inclusion of gabapentin for the treatment of this condition (Northcott et al, 2017). Unfortunately, both gabapentin and pregabalin are associated with side effects and one study reported that one in four were unable to tolerate either drug and therefore stopped taking them (Wiffen et al, 2013). Topimarate is used for the management of epilepsy, but has also been examined for any possible benefits in patients with fibromyalgia. Study results have been disappointing with no effect on pain at all, but resulting in more side effects, which made many people withdraw from the studies early (Wiffin et al, 2013).
Benzodiazepines
Drugs such as diazepam may be useful initially for reestablishing a more acceptable sleep pattern, but should only be prescribed as a short course as long-term use is associated with dependence and difficulty stopping the drug if given longer term (Joint Formulary Committee, 2020). Alternatives are hypnotics (such as zopiclone and zolpiderm), British National Formulary guidance indicates drugs of this type should be given for short term use only (Joint Formulary Committee, 2020).
Opioids
Opioid drugs (such as morphine and tramadol) are widely used for the management of pain, and have therefore been studied for their benefits in patients with fibromyalgia. Three small studies reported that pain was reduced by half or more in some people prescribed tramadol, although side effects were experienced by six in 10 of those taking the drug (Duehmke et al, 2017).
Non-steroidal anti-inflammatory drugs
NSAIDs are relatively cheap to buy over the counter and patients who incur prescription charges may wish to try them. However, they have not been shown to be particularly effective in relieving fibromyalgia pain. As with opiods, Eular guidelines do not recommend their use in fibromyalgia based on lack of efficacy (Mcfarlane et al, 2016).
Other medications
Capsaicin
Topical creams with capsaicin have been used to treat the pain and discomfort caused by neuropathic type pain. There are formulations containing high and low doses of the drug with research studies reporting variable success rates. In order to attempt to increase the amount of the active substance delivered, high-concentration (8%) capsaicin patches were developed. The 8% patch has a capsaicin concentration about 100 times greater than conventional creams and a single application of a high-concentration (8%) patch for 30-90 minutes provides significant pain relief for up to 12 weeks in some people with chronic pain arising from postherpetic neuralgia or HIV-neuropathy (Derry et al, 2017).
High-concentration topical capsaicin is given as a single patch application to the affected part, under highly controlled conditions, normally under local anaesthetic, and the benefits are expected to last for about 12 weeks, when another application might be made (Derry et al, 2017).
Non pharmacological treatments
Education
Patient education has proved beneficial and has achieved significant clinical benefits across a number of conditions, such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis (Adams, 2010). When used as part of the treatment and management plan in patients with fibromyalgia, it has been shown to play a vital part in helping the patient to understand their condition and learn how to cope with their symptoms on a daily basis. An awareness of the chronic nature of the illness, and an understanding of the fact that they will have good days and bad days, and an ability to recognise and manage flare ups will help patients learn to cope. The patient also needs to be aware that although treatment will improve their symptoms, unfortunately it is unlikely that they will be completely resolved.
Cognitive behavioural therapy
Patient with fibromyalgia often suffer from stress and anxiety and one of the aims of treatment is to improve the patient's perception of the disease, and improve coping mechanisms. The primary goal of cognitive behavioural therapy treatment is to increase self-management, which includes moving patients toward more adaptive beliefs regarding their ability to cope with and control pain and other symptoms, as well as taking action to decrease fibromyalgia symptoms and stress resulting in increased functioning (Hassett and Gevirtz, 2009).
Complimentary therapies
There a range of alternative and complementary therapies available such as hydrotherapy, acupuncture, and massage treatment to name but a few. Acupuncture is available on the NHS but many other therapies are not. Options such as hydrotherapy, massage and hypnotherapy are not recommended on the basis that there is insufficient evidence to support their use (Mcfarlane et al, 2016). However, despite the fact that patients generally have to pay for treatments of this type, they may still be a popular choice for some patients, despite the fact that at the current time there is little evidence to support their use in fibromyalgia.
Exercise
Exercise has long been recognised as beneficial in preventing onset of some potentially serious conditions such as heart disease and Type 2 diabetes. In patients with fibromyalgia, aerobic exercise and muscle strength training has been shown to have multiple benefits. Starting slowly and gradually increasing the level of intensity will reduce the risk of a flare up or physical injury. Choosing an activity, the patient enjoyed before the onset of their illness (swimming, walking, activities in groups, etc) increases the likelihood that they will persevere. Exercise improves oxygenation and circulation to muscles, improves mood, reduces disability, and helps restore a normal sleep pattern and should be undertaken 2-3 times per-week (Dedhia and Bone, 2009). Pacing activities, and balancing periods of activity with rest, allows the person to gradually increase exercise levels improving fitness levels.
Prognosis
Although interest and knowledge of fibromyalgia has increased in recent years, it is impossible to predict prognosis, largely because of the variation in severity, symptoms and the likelihood of additional comorbidities.
Conclusion
Fibromyalgia is clearly a distressing and debilitating disease capable of causing considerable disruption to the lives any affected person. For clinicians, prescribing for multiple symptoms is highly challenging. Choosing the best available treatment for the patients most prominent symptoms is in itself problematic as there is a need to consider the patients, age, comorbidities, current medications, drug interactions and adverse effects. Although there is greater awareness of this illness and its impact, it is clear that further research is needed. It is hoped that in the future newer targeted treatments will become available, making to task of prescribing for this patient group much simpler. This article has aimed to give non-medical prescribers some insight into currently available treatment options and hopes to give.
Key Points
- The severity of Fibromyalgia can vary from person to person
- Fibromyalgia may require multiple treatments
- Non-pharmacological and pharmacological treatments are available for Fibromyalgia
- Non-pharmacological treatments are usually tried first
CPD reflective questions
- Think about difficulties in diagnosis and how we can improve pathway for patients
- Think about offering a holistic approach to treatment and choosing non-pharmacological and pharmacological options
- How can we monitor patients, reviewing their response to treatment and assess whether alternative options are needed?