Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 12
Experts offer their clinical experience with nonsteroidal anti-inflammatory drugs (NSAID) in the treatment of fibromyalgia (FM).
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Let's talk about the role of NSAIDs. I have not heard any of you mention NSAIDs. My experience is they're not helpful, but I'm wondering what you all think.
Kostas Botsoglou, MD: By the time they make it to our office, they've already tried multiple NSAIDs over the counter prescription strength. We'll use it for if they have any concomitant arthritis, which is common.
Benjamin Natelson, MD: And again, for some of my patients if their circulating immune complexes are high, their SED rate, their ESR, their ANA, I will do a brief trial of steroids, and if it's positive, ask the help of rheumatologists. But I find that unless the rheumatologist can detect peripheral signs of inflammation that doctor just writes it off what do you think, Dan, am I wrong in that?
Daniel Clauw, MD: Well, it's probably beyond this conversation- there is some neurogenic inflammation in fibromyalgia, no aplastic pain, but it doesn't seem to be responsive to NSAIDs or even to the drugs we use to treat our autoimmune diseases. It's a different type of inflammation. But I think that there are people with fibromyalgia that, again, have comorbid osteoarthritis, comorbid this, and whom men NSAID is helpful. It's just not going to help for the fibromyalgia pain. It's not going to help very much for the fibromyalgia component of the pain.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Dr Clauw, say you're just not using opioids, but if you go to opioids? Is there a particular one any of you use? As I mentioned, if I have people at all on anything, it would be tramadol based on the studies that I've seen. But I'm wondering about the rest of you.
Daniel Clauw, MD: I don't tramadol's such a weak opioid. I review manuscripts that rank Tramadol with the rest of opioids, I say, please, when it first came out, it wasn't even a controlled substance. That's how weak.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Absolutely.
Daniel Clauw, MD: We should think of tramadol and it's, an SNRI it's probably a lot of the activity of tramadol and fibromyalgia from the SNRI activity at tramadol, not from the weak opioids. I don't have any problem with people using tramadol. It's the stronger opioids. I think again, where a lot of us are really concerned.
Benjamin Natelson, MD: For those few patients who have, are still suffering major four quadrant pain, despite being on wo anti-epileptic drugs and perhaps an SNRI, I'll start about 15 mg of MS-Contin once or twice a day and then go up to a dose where their pain is under control. Again, it's a very, it's a minority of patients. And, fore I do that, I'll try experimental ways to improve sleep. I use Oxybate. I'm sure neither of my colleagues use oxybate in their practice because it's heavily controlled and once you're an oxybate prescriber, it's OK. That's a drug. Xyrem and Xywav is a drug that was on its way to FDA approval for FM until the FDA said Uh-huh. Because it's a variant of it is a street drug and it's dangerous short acting, but in the right hands it improves the quality of sleep. And those early studies said it reduced pain significantly. FM pain.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I think that that's the drug that has a REMS program associated with it. Correct. And it also, is it indicated for narcolepsy or no?
Benjamin Natelson, MD: Yes. Its major indications are narcolepsy and most recently idiopathic hypersomnia. And I believe it's also indicated for sleep apnea that is resistant to CPAP with pain.
Transcript edited for clairy.