Fibromyalgia Syndrome

Seong-Ho Kim

doi:10.4078/jkra.2009.16.1.1

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Kim: Fibromyalgia Syndrome

Original Article

J Korean Rheum Assoc 2009;16(1):1-15.

Published online: 20 March 2009

DOI: https://doi.org/10.4078/jkra.2009.16.1.1

Fibromyalgia Syndrome

Seong-Ho Kim

Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Korea

Received 18 February 2009 Accepted 24 February 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Fibromyalgia syndrome is a major cause of chronic widespread pain and this affects 2.2% of all Koreans. Evidence exists for a genetic contribution to fibromyalgia. Those people who are predisposed to develop fibromyalgia may have this condition “triggered” by a variety of environmental “stressors,” including certain types of infections, physical trauma and catastrophic events. Some patients with fibromyalgia have been found to have abnormalities in a number of the body's “stress response” systems, including the hypothalamus-pituitary-adrenal axis and the autonomic nervous system. The most consistently detected objective abnormalities in fibromyalgia involve the pain-processing systems. Patients with fibromyalgia have displayed quantitative abnormalities in pain perception under experimental conditions. Fibromyalgia may be related to a decrease in the activity of the descending, antinociceptive pathways. In addition to neurobiologic mechanisms, psychologic and behavioral factors also play a role for many patients for the different symptoms they express. Diagnosing and treating these patients is especially challenging due to the limited knowledge of the etiology of this disease and the poor response to conventional pain treatments. Strict adherence to the ACR classification criteria in clinical practice is not required to effectively treat patients with fibromyalgia. The treatments of fibromyalgia should be targeted to the central pain and the neuropsychological symptoms. Current evidence advocates a multifaceted program that emphasizes patient education, medications for improving symptoms and aggressive use of exercise and cognitive-behavioral therapy to restore function.

Keywords: Fibromyalgia, Chronic pain

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Fig. 1.

The ‘systemic' conditions that overlap with fibromyalgia.

Fig. 2.

Regional or localized syndromes that overlap with fibromyalgia for thier prevalence, mechanisms and treatment (4).

Fig. 3.

The functional magnetic resonance imaging (fMRI) responses to painful pressure applied to the left thumb in patients with fibromyalgia and in healthy control subjects. In the top left panel, the individuals with fibromyalgia (▲) and who were given a low pressure stimulus have similar levels of pain and neuronal activation in areas of the brain that are known to be involved in pain processing (ends of arrows) as the controls, and the controls were given nearly twice as much pressure. The controls, when given the same low pressure that caused pain in the fibromyalgia patients, they rated their pain as 2/20 instead of 12/20, and they show no neuronal activation with this amount of pressure (24).

Fig. 4.

Subgroups of fibromyalgia patients based on grouping by psychological, cognitive and neurobiological (the degree of hyperalgesia) factors (50).

Fig. 5.

Strategic polypharmacy for a fibromyalgia patient with three prominent domains (pain, insomnia and depression). The combined use of either pregabalin or oxybate along with duloxetine could be considered because their mechanisms of action and elimination are quite different. Since there is very little research data and experience with such a regimen, it must be tailored to the individual patient and the patient must be carefully monitored (85).

Fig. 6.

Algorithm for the diagnosis and treatment of fibromyalgia (13).

Fig. 7.

An example of dually focused treatment (4).

Table 1.

Pharmacologic treatments of fibromyalgia

Agent	Mechanism	Dosage/Adverse effects
Gabapentin	Alpha-2-delta ligand; affects calcium flux and release of excitatory amino acids and neuropeptides	Should be used in divided doses three times daily for optimal effect; most will require 1,200∼2,400 mg/day, but start with lower dose and increase to minimize adverse effects; dizziness and somnolence may limit tolerability
Pregabalin	Alpha-2-delta ligand; affects calcium flux and release of excitatory amino acids and neuropeptides	Approved by US FDA at 300 and 450 mg/day taken in divided doses twice daily, but start with lower dose and increase to minimize adverse effects; dizziness and somnolence may limit tolerability
Amitryptiline and related tricyclic compounds	Norepinephrine and serotonin reuptake inhibitors with additional anticholinergic, antiadrenergic, antihista-minergic, and quinidine-like effects	Pleotrophic actions increase side effects; should be avoided in the elderly and those with heart problems
Fluoxetine	Serotonin reuptake inhibitor	Have more important effects on mood than on pain, but higher doses may improve analgesic effects; more serotonin-selective agents have not been effective for relief of pain
Duloxetine	Balanced norepinephrine and serotonin reuptake inhibition	Approved for treatment of neuropathic pain; no evidence that twice daily dosing provides significant improvement in efficacy; starting with lower dose and increasing to 60 or 90 mg daily is recommended; GI effects may limit tolerability; can cause insomnia
Milnacipran	Balanced norepinephrine and serotonin reuptake inhibition	Likely requires divided dosing and most will require 200 mg/day; GI side effects may limit tolerability
Tramadol with or without acetaminophen	Mu-opioid receptor agonist, norepinephrine and serotonin reuptake inhibition	May be associated with withdrawal with discontinuation and with abuse and dependence; adverse effects include nausea, constipation, dizziness and

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