Fibromyalgia Syndrome: Care and Controversies
Melanie Swims, PharmD, BCPS*
This issue of University of Tennessee Advanced Studies in Pharmacy summarizes the proceedings of a roundtable held in Boulder, Colorado, on June 5, 2009. The roundtable focused on a variety of issues encountered in the management of fibromyalgia syndrome (FMS), which affects 3 million to 6 million Americans1 most of them women between 20 and 50 years of age.2,3
Placing particular emphasis on the role of the managed care and community pharmacist in managing patients with FMS, the roundtable faculty addressed the clinical characteristics and multifactorial etiologies of the syndrome, the pharmacologic and nonpharmacologic approaches to treatment, and the barriers to appropriate care. Members of the distinguished faculty included a neurologist with expertise in managing FMS and other pain and fatigue syndromes, a clinical psychologist, and 5 pharmacists representing academic, community, hospital, and managed care pharmacy practice.
Fibromyalgia syndrome is a frequently misunderstood illness,3 with no definitive diagnosis and no consensus on its specific cause.4 It is characterized by widespread musculoskeletal pain and tenderness, and is often accompanied by fatigue, sleep disturbances, depressed mood, irritable bowel syndrome, and cognitive difficulties.5,6 Accumulating scientific evidence suggests that FMS is a disorder of central pain processing and not simply a somatic syndrome.7
Most patients with FMS fail to respond adequately—or for any significant length of time—to non-steroidal anti-inflammatory drugs, opioids, surgical procedures, or injections.8 Typically, they visit multiple healthcare providers in search of symptomatic relief and receive multiple medications that produce inconsistent results. Many are flatly told that "there's nothing wrong; it's all in your head" or are written off as "difficult patients" or "chronic complainers."9 This invariably gives rise to feelings of frustration, anger, and hopelessness.
Further complicating this situation is the fact that many patients do not receive effective treatment because many healthcare providers do not know how to treat FMS and are eager for education about the syndrome and how to treat it appropriately. It is in this arena that the managed care and community pharmacist who is knowledgeable about FMS can provide patients and physicians with information, healthcare reinforcement, and strategies for implementing FMS interventions and promoting patient adherence to treatment regimens. As the most accessible healthcare professionals, managed care and community pharmacists are ideally positioned to listen empathetically to patients with FMS, assist them in finding the best care available, and guide them in managing overall treatment and recognizing medication side effects.
Although there is still much to learn about FMS, it is clear that a patient- and symptom-specific approach that incorporates pharmacologic and nonpharmacologic modalities is the first step in successful treatment.
In his presentation on FMS and other medically unexplained illnesses, Benjamin H. Natelson, MD, describes the prototypic presentation of FMS and notes that the recent approval of drugs indicated for the syndrome has changed the treatment equation for physicians. He addresses the frequent coexistence of FMS and other unexplained illnesses such as chronic fatigue syndrome and multiple chemical sensitivity, and points out that the more unexplained illnesses the patient with FMS has, the higher the risk of a comorbid Axis I major depressive disorder. Dr Natelson also underscores the need to take the patient with FMS and her symptoms seriously, and presents his own incremental algorithm that involves pharmacologic options to relieve pain and tenderness, as well as rehabilitative modalities to improve functioning.
Arthur G. Lipman, PharmD, FASHP, continues with a closer look at FMS and the functional disorders that most commonly accompany the syndrome. He discusses several physical, psychiatric, immunologic, and other factors that play contributory roles in the etiology of FMS, and describes a recently published hypothesis for the pathophysiology of FMS that attributes the syndrome to a genetic predisposition that activates neuroendocrine, neurotransmitter, and neurosensory dysfunction, ultimately producing clinical symptoms in response to triggering events. Dr Lipman also reviews the pharmacologic and nonpharmacologic options that are commonly employed to treat FMS and its comorbidities.
Jacquelyn Bainbridge, PharmD, FCCP, follows with an overview of the central and peripheral pain processing abnormalities believed to be involved in the etiology of FMS. She then discusses the mechanism of action, pharmacokinetics, dosing information, side-effect profile, contraindications, precautions, and drug interactions for each of the 3 drugs recently approved for the treatment of FMS. Dr Bainbridge concludes with a case presentation to help healthcare providers and pharmacists formulate a treatment plan based on currently approved therapies and tailored to meet the patient's needs.
In the final presentation, Kathryn L. Hahn, PharmD, DAAPM, CPE, identifies several barriers to care and provides some practical advice on how to overcome these barriers to improve care. Barriers encountered by providers include lack of education about FMS and persistent questions about whether FMS is "real" or not. Barriers encountered by patients and providers alike include an intense patient history, the complexity of treating FMS, and the lack of cost-effective care. Dr Hahn suggests several strategies that managed care and community pharmacists can implement to overcome these barriers, including patient and provider education, communication, empathy, medication counseling, patient advocacy, and use of assessment tools.
Each of the 4 articles presented in this issue of University of Tennessee Advanced Studies in Pharmacy features discussion highlights from the entire faculty, which also includes Kenneth L. Kirsh, PhD, Pete Penna, PharmD, and Scott Strassels, PharmD, PhD, BCPS.
As suggested in the material presented here, there has been some progress in the management of patients with FMS in recent years. However, additional research remains to be done in pinpointing the etiology and pathophysiology of FMS. New and future therapies, as well as the implementation of strategies to overcome barriers to care, underscore the integral role of the pharmacist in improving clinical care.
1. Statistics about Fibromyalgia. WrongDiagnosis.com. Available at: http://www.wrongdiagnosis.com/f/ fibromyalgia/stats.htm. Accessed June 17, 2009.
2. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76:247-254.
3. Peterson E. Fibromyalgia: management of a misunderstood disorder. J Am Acad Nurse Pract. 2007;19:341-348.
4. Abeles AM, Pillinter MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007;146:726-734.
5. Arnold LM, Pritchett YL, D'Souza DN, et al. Duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized, placebo-controlled clinical trials. J Women's Health. 2007;16:1145-1156.
6. Lloyd KB, Berger BA. Communication concerning sensitive issues: fibromyalgia. US Pharm. 2007;32:61-65.
7. Adler GK, Geenen R. Hypothalamic-pituitary-adrenal and autonomic nervous system functioning in fibromyalgia. Rheum Dis Clin North Am. 2005;31:187-202.
8. Goldenberg DL, Burckhardt C, Crofford L. Clinical review: management of fibromyalgia syndrome. JAMA. 2004;292:2388-2395.
9. Natelson BH. Your Symptoms Are Real. What to Do When Your Doctor Says Nothing Is Wrong. New York, NY: John Wiley & Sons, Inc: 2007.
*Associate Professor, Department of Pharmacy, University of Tennessee; Clinical Pharmacy Specialist, Ambulatory Care, Veterans Affairs Medical Center, Memphis, Tennessee.
Address correspondence to: Melanie Swims, PharmD, BCPS, University of Tennessee, Veterans Affairs Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104. E-mail: firstname.lastname@example.org.