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Fibromyalgia

Updated : February 27, 2024





Background

The condition fibromyalgia (FM) is characterized by chronic musculoskeletal discomfort throughout the body. This illness is frequently accompanied by fatigue, cognitive impairment, psychiatric symptoms, and various somatic symptoms.

Fibromyalgia has an undetermined etiology and pathogenesis. Despite the presence of tenderness in soft tissues being characteristic of this illness, there is no signs of tissue inflammation.

According to continuing research, fibromyalgia is a pain regulation disorder, classified as a sort of central sensitization syndrome. Today, fibromyalgia is recognized as a neurosensory disease in which the brain is unable to process pain.

Epidemiology

Fibromyalgia is far more prevalent in women than in men, with an average frequency of 6.4% in the US, its incidence rate is 4.9% in men, and 7.7% in women.  Studies in South America and Europe demonstrate a range between 3.3%-8.3%. This condition is progressive with age.

Between the ages of 20 and 55, fibromyalgia is the most common cause of nonspecific musculoskeletal pain in women. According to numerous studies, the prevalence among adolescents is comparable to that of adults.

Over 40% of individuals sent to a tertiary care pain clinic fit the criteria for fibromyalgia. A significant risk factor for this condition is existent rheumatic disease.

Anatomy

Pathophysiology

Fibromyalgia is a problem with pain regulation or processing in the brain. Individuals affected present with hypersensitivity to pain perception. Other psychological problems are also linked with this persistent hypervigilance of pain.

Some abnormalities observed in this condition are:

  • Dysregulated dopamine mechanism
  • Elevation of excitatory neurotransmitters such as substance P and glutamate
  • Changes in brain endogenous opioid activity
  • Lower levels of norepinephrine and serotonin in the anti-nociceptive spinal cord pathways
  • Prolongation of pain sensations

Women are more likely to be affected than men because of the use of maladaptive coping mechanisms, higher levels of anxiety and depression, hormonal changes related with the menstrual cycle, and altered behavior in response to pain.

Etiology

Fibromyalgia is a condition characterized by chronic pain and no specific etiology.  This illness is triggered or exacerbated by various emotional or physical stressors, including physical and emotional trauma, as well as infections. Several studies have demonstrated a genetic tendency for fibromyalgia, although no clear candidate gene has been identified.

It s characterised by pain and abnormalities in the CNS’s sensory processing. Compared to healthy controls, patients perceive noxious stimuli as painful at lower levels of physical stimulation. When fibromyalgia patients are exposed to rapidly repeated, brief, unpleasant stimuli, they report greater than average elevations in the perceived intensity of pain.

People with fibromyalgia appear to have an impairment in their endogenous analgesic systems. Using functional neuroimaging techniques, it has been demonstrated that there are disparities in the activation of pain-sensitive brain regions.

Genetics

Prognostic Factors

Several studies indicate that individuals treated by primary care physicians have a much better prognosis than patients treated in tertiary referral centers. Long-term studies have observed persistent chronic fatigue and pain in patients treated at these centers.

Multiple psychosocial and demographic factors affect outcomes in individuals suffering with this condition. Some factors which indicate a worse outcome are obesity, unemployment, depression, history of abuse, and socioeconomic status.

Most patients have a poor prognosis, and certain factors are especially associated with the same.

These include:

  • Dependance on addictive substances
  • High levels of stress
  • Functional impairment
  • Inadequately treated anxiety or depression
  • Long disease duration

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

flupirtine 

It has been used to treat fibromyalgia, a condition marked by pain and tenderness in the musculoskeletal system that is widespread
Adults should usually start with a dose of 100 mg, three times a day. Depending on the patient's response to treatment and the degree of their pain, the total daily dose may be adjusted to 400 mg. The total daily dose may be raised to 600 mg in certain circumstances, but this should only be done with a doctor's approval



Dose Adjustments

Renal dose adjustments
For people with normal renal function, no dose change is usually required. When there is mild renal impairment (eGFR 60-89 mL/min/1.73 m2), usually no dose modifications are needed
Adult dosage recommendations may be lowered in moderate renal impairment (eGFR 30-59 mL/min/1.73 m2). 50 mg three times a day as a starting dose is suitable in many circumstances. Doses taken in total each day may vary from 150 mg to 200 mg
When using flupirtine in patients who have severe renal impairment, caution should be exercised

milnacipran 

Dosing Modifications
Renal impairment
Mild: dosage adjustment is not required
Moderate: should be used with caution
Severe: decrease maintenance dose to 50% (i.e., to 50 mg/day every 12hr)
End-stage renal disease (ESRD): not recommended to use
Hepatic impairment
Mild or moderate: dosage adjustment is not required
Severe: should be use:

12.5 mg orally once on day 1, following 25 mg/day every 12hr from days 2-3, following 50 mg/day every 12hr from days 4-7, following 100 mg/day every 12hr after that should not exceed more than 200 mg/day
Therapy discontinuation
While discontinuing the therapy after more than 3 weeks, gradually taper the dose from 2-4 weeks
Switching to or from MAO inhibitors
Allow 5 or more days to discontinue milnacipran and initiation of MAO inhibitor
Allow 14 days to discontinue MAO inhibitor and initiation of milnacipran
Increase to 50 mg twice a day for severe renal impairment



pregabalin 

oral solution and Regular-release capsules only
75 mg orally every 12 hours initially (150 mg each day)
Maintenance: After one week, increase to 150mg every 12 hours as required; the recommended dosage is 300-400 mg/day
Doses more than 450 mg/day are not advised due to dose-dependent adverse effects



 

pregabalin 

The Safety and efficacy were not established
A 15-week, placebo-controlled study (n=107) with pregabalin (75-450 mg/day) was done in pediatric patients with fibromyalgia ages 12-17 years



Dose Adjustments

Dosage Modifications
Renal impairment: not studied in children with the compromised renal function

 

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK540974/

Fibromyalgia

Updated : February 27, 2024




The condition fibromyalgia (FM) is characterized by chronic musculoskeletal discomfort throughout the body. This illness is frequently accompanied by fatigue, cognitive impairment, psychiatric symptoms, and various somatic symptoms.

Fibromyalgia has an undetermined etiology and pathogenesis. Despite the presence of tenderness in soft tissues being characteristic of this illness, there is no signs of tissue inflammation.

According to continuing research, fibromyalgia is a pain regulation disorder, classified as a sort of central sensitization syndrome. Today, fibromyalgia is recognized as a neurosensory disease in which the brain is unable to process pain.

Fibromyalgia is far more prevalent in women than in men, with an average frequency of 6.4% in the US, its incidence rate is 4.9% in men, and 7.7% in women.  Studies in South America and Europe demonstrate a range between 3.3%-8.3%. This condition is progressive with age.

Between the ages of 20 and 55, fibromyalgia is the most common cause of nonspecific musculoskeletal pain in women. According to numerous studies, the prevalence among adolescents is comparable to that of adults.

Over 40% of individuals sent to a tertiary care pain clinic fit the criteria for fibromyalgia. A significant risk factor for this condition is existent rheumatic disease.

Fibromyalgia is a problem with pain regulation or processing in the brain. Individuals affected present with hypersensitivity to pain perception. Other psychological problems are also linked with this persistent hypervigilance of pain.

Some abnormalities observed in this condition are:

  • Dysregulated dopamine mechanism
  • Elevation of excitatory neurotransmitters such as substance P and glutamate
  • Changes in brain endogenous opioid activity
  • Lower levels of norepinephrine and serotonin in the anti-nociceptive spinal cord pathways
  • Prolongation of pain sensations

Women are more likely to be affected than men because of the use of maladaptive coping mechanisms, higher levels of anxiety and depression, hormonal changes related with the menstrual cycle, and altered behavior in response to pain.

Fibromyalgia is a condition characterized by chronic pain and no specific etiology.  This illness is triggered or exacerbated by various emotional or physical stressors, including physical and emotional trauma, as well as infections. Several studies have demonstrated a genetic tendency for fibromyalgia, although no clear candidate gene has been identified.

It s characterised by pain and abnormalities in the CNS’s sensory processing. Compared to healthy controls, patients perceive noxious stimuli as painful at lower levels of physical stimulation. When fibromyalgia patients are exposed to rapidly repeated, brief, unpleasant stimuli, they report greater than average elevations in the perceived intensity of pain.

People with fibromyalgia appear to have an impairment in their endogenous analgesic systems. Using functional neuroimaging techniques, it has been demonstrated that there are disparities in the activation of pain-sensitive brain regions.

Several studies indicate that individuals treated by primary care physicians have a much better prognosis than patients treated in tertiary referral centers. Long-term studies have observed persistent chronic fatigue and pain in patients treated at these centers.

Multiple psychosocial and demographic factors affect outcomes in individuals suffering with this condition. Some factors which indicate a worse outcome are obesity, unemployment, depression, history of abuse, and socioeconomic status.

Most patients have a poor prognosis, and certain factors are especially associated with the same.

These include:

  • Dependance on addictive substances
  • High levels of stress
  • Functional impairment
  • Inadequately treated anxiety or depression
  • Long disease duration

flupirtine 

It has been used to treat fibromyalgia, a condition marked by pain and tenderness in the musculoskeletal system that is widespread
Adults should usually start with a dose of 100 mg, three times a day. Depending on the patient's response to treatment and the degree of their pain, the total daily dose may be adjusted to 400 mg. The total daily dose may be raised to 600 mg in certain circumstances, but this should only be done with a doctor's approval



Dose Adjustments

Renal dose adjustments
For people with normal renal function, no dose change is usually required. When there is mild renal impairment (eGFR 60-89 mL/min/1.73 m2), usually no dose modifications are needed
Adult dosage recommendations may be lowered in moderate renal impairment (eGFR 30-59 mL/min/1.73 m2). 50 mg three times a day as a starting dose is suitable in many circumstances. Doses taken in total each day may vary from 150 mg to 200 mg
When using flupirtine in patients who have severe renal impairment, caution should be exercised

milnacipran 

Dosing Modifications
Renal impairment
Mild: dosage adjustment is not required
Moderate: should be used with caution
Severe: decrease maintenance dose to 50% (i.e., to 50 mg/day every 12hr)
End-stage renal disease (ESRD): not recommended to use
Hepatic impairment
Mild or moderate: dosage adjustment is not required
Severe: should be use:

12.5 mg orally once on day 1, following 25 mg/day every 12hr from days 2-3, following 50 mg/day every 12hr from days 4-7, following 100 mg/day every 12hr after that should not exceed more than 200 mg/day
Therapy discontinuation
While discontinuing the therapy after more than 3 weeks, gradually taper the dose from 2-4 weeks
Switching to or from MAO inhibitors
Allow 5 or more days to discontinue milnacipran and initiation of MAO inhibitor
Allow 14 days to discontinue MAO inhibitor and initiation of milnacipran
Increase to 50 mg twice a day for severe renal impairment



pregabalin 

oral solution and Regular-release capsules only
75 mg orally every 12 hours initially (150 mg each day)
Maintenance: After one week, increase to 150mg every 12 hours as required; the recommended dosage is 300-400 mg/day
Doses more than 450 mg/day are not advised due to dose-dependent adverse effects



pregabalin 

The Safety and efficacy were not established
A 15-week, placebo-controlled study (n=107) with pregabalin (75-450 mg/day) was done in pediatric patients with fibromyalgia ages 12-17 years



Dose Adjustments

Dosage Modifications
Renal impairment: not studied in children with the compromised renal function

https://www.ncbi.nlm.nih.gov/books/NBK540974/