Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 18

Combination Therapies and FM

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Experts discuss the limited combination therapy options for the treatment of fibromyalgia (FM) and how to inform patients of prospective outcomes.


Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: What do you think about combining therapies? We've already talked about using something like a duloxetine with gabapentin. What are your typical combination therapies and what does the evidence show? Is there any evidence out there showing efficacy?

Benjamin Natelson, MD: There's no evidence on efficacy of multiple anti-epileptic, that's for sure. All this is empiric. The practice of medicine is very empiric still. I mean we have FDA approved medicines, but if a patient is still suffering, we can do one of two things. Tell them what I can do for them or try something else. I'm willing to try other medicines and try to personalize it to the patient as much as I can, but sometimes you really are unable to help the patient despite your best efforts.

Kostas Botsoglou, MD: And that's the art of medicine, right?

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

Kostas Botsoglou, MD: I also like to set the expectations with the patients and advise them. These are the options we have. We'll start here. We'll work our way up. I also give them some realistic expectations that if we don't reach these goals, I may have to send you out elsewhere.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: One of the things for me that I feel like is important as I'm working with my patients is setting that realistic goal that I'm not going to cure your pain. You're not going to go to a pain level of zero. But if I can reduce your pain by 30% as we add on and augment and combine these different therapies, that's what I'm looking to do. It's to see if I can get you to a more functional, and I'll use a functional tool, like a brief pain index to see if I'm improving their function, in addition to reducing their pain. Those are the things that I try to do because we did our patients a disservice when we said we're going to cure your pain.

Benjamin Natelson, MD: Sure.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: And we're not going to cure their pain. We're going to mitigate their pain and hopefully improve their overall quality of life and their function.

Benjamin Natelson, MD: Absolutely.

Daniel Clauw, MD: In the pain field, for some time, there's been a focus more on improving function and getting people to attend to that. Also, to be aware that it can be highly motivating to a patient to ask them what are 1 or 2 things that your pain is precluding you from doing right now that you'd like to be able to do. You'd like to play nine holes of golf or be able to pick up your grandchild or whatever. Those personally meaningful functional goals are often very motivating for patients. Way more so than their VAS pain score going from a 6 to a 3, which we might care about, but they don't care at all about. They care about what they can do, so that's–I think in practice, if you're not trained in pain, sometimes you attend too much to the pain and not enough to the what is someone functionally unable to do and how can we help motivate them to do better.

Transcript edited for clarity.