Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 17

Step Approach for FM Treatment

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Experts discuss their step therapy approaches for the treatment of fibromyalgia (FM).


Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I know Dr Natelson gave us his step approach as to how he starts these different agents. Do either of you two have any thoughts about what is that kind of step approach? What do you use to start patients on these agents?

Kostas Botsoglou, MD: I typically start with the anticonvulsants. Gabapentin primarily try to titrate up to a to a level at least up to three times a day then I'll introduce duloxetine thereafter whether in combination or as monotherapy. But then I really try to avoid going to the opioids and going to the more controlled substances after that. That's where I'll refer them out to perhaps a pain specialist.

Benjamin Natelson, MD: Have either of you ever tried mexiletine?

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: No. I've seen that with some of my headache patients who have gone to tertiary centers but my chronic daily folks, but I have not used it for this. What about you, Dr Clauw?

Daniel Clauw, MD: It depends on a neurologist so he's comfortable using these drugs but none of these have been tested in fibromyalgia and they're widely used by neurologists that treat neuropathic pain and things like that but they're not most of us don't think of using these drugs. I'm not saying that they don't work. I'm saying we don't know that they do work. There are no trials showing that they work in conditions like fibromyalgia.

Benjamin Natelson, MD: He's right. But when I have a desperate patient, if I can try something rather than opioids, I'll try something and then ultimately, I will go to the opioids. I understand your hesitation and I understand Dan, but if someone is bedridden with horrible pain I just I won't ignore it. I'll try it. And if the opioids don't work, then we taper them off.

Transcript edited for clarity.