Understanding Fibromyalgia; How Experts are Diagnosing and Treating Their Patients - Episode 10
Experts discuss treatment options for fibromyalgia (FM) and how they utilize integrative care with patients.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Let's look now and talk about some treatment options for patients with fibromyalgia as we're moving toward the middle end of our program. Let's start, if we can, with some medical therapies. And let's talk about just an overarching what drugs are out there, where the evidence really supports, and then we're going to deep dive into each of them. But can you just throw out some of the drugs that have indications or have been shown promise in trials?
Daniel Clauw, MD: Well, tricyclic drugs, we're probably not going to talk aloud about, but those have been shown to be promising, especially cyclobenzaprine. People don't think of cyclobenzaprine as being a tricyclic, but it's almost identical structurally to amitriptyline. And a low nighttime dose of cyclobenzaprine is still just a drug I've been using for 35 years. It's still a helpful 2.5, 5 mg of cyclobenzaprine a couple hours before bedtime.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I agree with you.
Kostas Botsoglou, MD: The SSL.
Benjamin Natelson, MD: I had used amitriptyline, but the side effects are not always, but often more of a problem. I've abandoned it for other treatments.
Kostas Botsoglou, MD: I was going to add that the SSRIs, duloxetine, fluoxetine, have been shown to help reduce pain and gross sleep, as well as alleviate the depressive symptoms associated with fibromyalgia.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: So, the SSRIs, SNRIs.
Benjamin Natelson, MD: The SSRIs are not terribly helpful, but the SNRIs have been shown.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I did see one study in the past on fluoxetine, maybe offering some benefit. But the SNRIs with the nor epinephrine impact, is where a lot of that has been positive. What about other therapies? For me, I have physical therapy on site. One of the things I often do with these patients is give a warm handoff to our physical therapists so that I can get them to move a little bit. But I also have found it's beneficial. What else are you all doing for supporting therapies?
Kostas Botsoglou, MD: We also use hydrotherapy or aquatherapy, especially in the cold winter months where we in our region here, that's been effective. And if I'm able to, I might connect them with the acupuncture as well.
Daniel Clauw, MD: We should mention that the evidence-based for a number of therapies that we used to in Western medicine be dismissive of and call complementary and alternative therapies has increased so much that we now are being asked not to use the term complimentary alternative, use the word integrative to talk about acupuncture, yoga, mindfulness, meditation, all of these different integrative therapies that can really be helpful. And it more and more as studies are done in pain condition after pain condition, these treatments really can be quite effective. And so, trying to surround people with a number of those yoga tai chi has been helpful in fibromyalgia. A lot of the hands-on therapies, chiropractic manipulation, even, again, I wouldn't have believed early in my career that the evidence base would be as strong as it is for chiropractic manipulation. A lot of those non-pharmacologic therapies can be helpful.
Benjamin Natelson, MD: And we did an uncontrolled trial of deep fibromuscular release, which is known as Rolfing and got a significant improvement in pre/post testing. But there you must have a therapist who knows how to do that.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Any other adjunctive or integrative therapies, I think in the world of chronic pain, tai chi, yoga, acupuncture, massage, osteopathic manipulation, all have some decent evidence to support efficacy. And I try to use those complimentary and integrative therapies as well.
Daniel Clauw, MD: There's 5 flavors of cognitive behavioral therapy. Ben talked about too, that cognitive behavioral therapy for pain and for insomnia. There's acceptance and commitment therapy or act there. And then there's a special therapy that seems to work extremely well in the subset of people that have a lot of trauma that's either called emotional awareness or neural reprocessing therapy. But this is one of the things that you rarely see people with fibromyalgia almost cured or 70, 80% better, but some of those individuals, they have a lot of trauma. They get that specific type of therapy can really be helped by it.
Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: One of the things we've not mentioned are opioids, and I would like us to have a conversation about that as we move through this program. I know that there are some studies out there using, for instance, something along the lines of a tramadol, and we'll have a conversation about that as we move along.
Transcript edited for clarity.