Daniel J. Clauw, MD

an overview of pharmacologic and nonpharmacologic therapeutic approaches for the management of fibromyalgia and challenges and unmet needs for patients

Approaching Management of Fibromyalgia and Unmet Needs in Treatment

This is a video synopsis of a discussion involving Daniel J. Clauw, MD, a professor of anesthesiology, medicine/rheumatology, and psychiatry at the University of Michigan. Dr. Clauw discusses the treatment approaches for fibromyalgia, emphasizing the increasing understanding that non-drug therapies are likely preferable in conjunction with pharmaceutical interventions.

He identifies three general categories of drugs that may be helpful for fibromyalgia: tricyclic drugs, serotonin-norepinephrine reuptake inhibitors (SNRIs), and gabapentinoids. Dr. Clauw introduces the concept of drugs as a "chemical nudge," helping individuals with fibromyalgia manage symptoms such as fatigue, pain, and sleep disturbances, enabling them to engage in non-drug therapies effectively. Non-pharmacologic strategies, including improving sleep, increasing activity levels, and stress reduction, play a significant role in managing fibromyalgia and nociplastic pain.

Dr. Clauw acknowledges the challenges in fibromyalgia care, including delayed identification and treatment initiation. He stresses the importance of early identification and aggressive treatment to prevent the accumulation of psychosocial factors that exacerbate pain and complicate treatment. Despite progress, there is still a need to overcome physician misunderstandings and reduce the stigma associated with fibromyalgia, advocating for a comprehensive approach to improve the lives of individuals with fibromyalgia-like pain.

Video synopsis is AI-generated and reviewed by HCPLive® editorial staff.

Videos

Dr Daniel J. Clauw provides an overview of pharmacologic and nonpharmacologic therapeutic approaches for the management of fibromyalgia and comments on challenges and unmet needs for patients.

the role the brain and CNS play in controlling nociplastic pain in patients with fibromyalgia and increased patient sensitivity to sensory stimuli

Impact of Brain on Nociplastic Pain for Fibromyalgia

This is a video synopsis of a discussion involving Daniel J. Clauw, MD, a professor of anesthesiology, medicine/rheumatology, and psychiatry at the University of Michigan. Dr. Clauw focuses on the management of fibromyalgia, a prototypical central pain condition, exploring terms such as nociplastic pain and central sensitization.

In the discussion, Dr. Clauw explains that fibromyalgia involves pain that is either amplified or caused by the central nervous system. He emphasizes that individuals with fibromyalgia not only experience pain but also suffer from associated symptoms, such as fatigue, sleep problems, memory issues, and mood disorders. These individuals exhibit heightened sensitivity not only to pain but also to various sensory stimuli, including light, noise, and odors.

The international group of pain researchers identifies nociplastic pain as the underlying mechanism in fibromyalgia, making it a poster child for this type of pain. Dr. Clauw highlights the multifaceted nature of fibromyalgia, linking it to a rapidly advancing understanding of the brain's involvement in the condition. Certain brain regions, such as the insula, are identified as crucial in amplifying the pain experienced by individuals with fibromyalgia.

Daniel J. Clauw, MD, describes the role the brain and CNS play in controlling the setting of nociplastic pain in patients with fibromyalgia and highlights increased patient sensitivity to sensory stimuli.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: 

In our last couple of questions, gentlemen, how can we, me as a primary care provider, and you, as my specialty colleagues- how can we work together, do you think, to help improve the care of these patients with fibro?

Have a full network of occupational therapists, physical therapists, mental health, in addition to some specialists in neurology and pain management.

And we need to encourage our third party payers to more broadly reimburse for these integrative therapies. It's so much easier to take care of someone with fibromyalgia when, again, they're getting cognitive behavioral therapy for insomnia and they're getting a little bit of acupressure and there's other providers and other people attending to them, and the evidence base for these therapies has really increased to the point now that they really should be broadly approved for almost any type of chronic pain.

And I would just add that all 11 nurse practitioners that work for me in my clinic, we read every note that you send in to us from the specialty, because we all learn a lot from the way you have set the bar and the education that you do in your consult notes, I just think that's just really important to keep up setting that bar with–because you have access to some of that latest information on the latest guidelines and treatments. As we're wrapping up tonight because our time has come to end this. This conversation has been so incredibly rich and informative. I've learned so much from all of you tonight and I want to thank you. But before we conclude this program, I'd like to ask each one of you to issue just a final thought that you have for our audience tonight. Dr Botsoglou, can you go first for us?

I just would like to share that this is a disease that is primarily seen in the primary care setting and with a multi-specialty approach and using modalities like aqua therapy, physical therapy, occupational therapy, in addition to pharmacologic therapy, we will be able to identify and treat these patients earlier and lead to less disease and morbidity.

Yes, just to segue, I really think one of the biggest problems of taking care of individuals with conditions like fibromyalgia, is we wait too long before we diagnose and start treating them. If we waited seven to eight years to take care of–start treating rheumatoid arthritis, those people wouldn't have any viable joints left or gout or something like that or heart disease, so I think that that long wait–especially people that are taking care of adolescents and individuals in their 20's, you can see fibromyalgia coming when these people start having these different pain conditions in different areas of their body. When that happens, these people should be aggressively treated then, rather than ignored and acted as if there is nothing wrong with them.

Again, like you pointed out earlier, giving the patient the diagnosis and establishing a good doctor-patient relation with good rapport leads to improved quality of life in and of itself. And then, putting the patient on the same page with you in terms of treatment and expectation, I think we can promise we will help them. But as you pointed out, Wendy, we're not going to be able to cure them. But if we emphasize that we can help them and they can do better and they can help themselves with gentle physical conditioning and some of the other things that were mentioned, which are non-medical, that's our job as doctors.

I agree, and I would just like to add that having a relationship with a primary care provider or with a specialist who believes that there truly is something wrong. As I often say to my patients, just because we don't have a lab test to diagnosis it or an imaging study to do, doesn't mean that this doesn't exist and so, giving them that diagnosis and forming a partnership with them, but not just focusing on pain, but also focusing on sleep and function can go a long way to improving their quality of life. It's been such a great evening and I thank you for watching this peer exchange. If you enjoyed the content, please subscribe to our newsletters to receive upcoming peer exchanges and other great content right in your inbox. Good night and goodbye for now.

Experts conclude their discussion emphasizing the importance of integrative care and how providers can improve outcomes for their patients with fibromyalgia (FM).

Prospective Advancements and Final Thoughts on the Treatment of FM

I'm not finding this, but I'm wondering if any of you are. Given that many of these medications are now generic, not all of them. But are there challenges in getting these medications covered by payers at this point? We heard earlier that, for instance, the Orexin Antagonists for sleep, we must often have a prior authorization done. But what about the medicines, Milnacipran? Are you seeing any issues? Duloxetine? Pregabalin? Gabapentin? Getting these drugs approved?

One reason why I select Gabapentin first is that I know I don't have to get it approved. It's so widely available and affordable. But if you want to transition to Pregabalin you must show–a prior authorization is required and you do have to demonstrate failure at least with a therapeutic dose of Gabapentin.

What do you think the biggest challenges are in terms of unmet needs for our patients with fibromyalgia?

Treatment and I guess my colleagues see patients on the severely ill end of that skewed spectrum and I'd like not to have to use an opioid so if there was anything that I could put in after I ramp up. I have this ramp up schedule, so if I didn't have to go to opioids, I'd love to have that tool.

The problem as I see it is we need to train a new group of providers to take care of people with chronic pain. The people that hang out a shingle in the United States as pain management have usually got a one-year fellowship to put needles into people. We really need people, providers to embrace the fact that in the right settings where they can provide integrative care, where they're not out on an island taking care of individuals on their own. Where they have more of a village. They can put someone in. In those systems, these patients get better. They're a lot easier to care for. But if you're a single, individual provider, who's trying to do this on your own, good luck.

In addition, having our primary care providers feel more comfortable and realize this doesn't have to be a specialist. This is something they see more often. They have the same tools that we have and it's something that can be easily treated rather than cycling through a variety of specialists and ultimately a delayed diagnosis, because as we mentioned, sometimes the diagnosis itself can be therapeutic for the patient.

Experts highlight current challenges in their practice treating patients with fibromyalgia (FM).

Daniel J. Clauw, MD

Articles