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Answer

D. Fibromyalgia

The diagnosis of fibromyalgia (FM) is made clinically based on the characteristic medical history and physical exam. For the condition to be diagnosed, chronic symptoms must have been present for over three months. Widespread pain and tenderness must be reported above and below the waist, as well as along the axial spine bilaterally. Associated symptoms include fatigue, sleep disturbances, and cognitive or mood disorders leading to impairment of activities of daily living. Patients have a lifetime prevalence of depression and anxiety of 74 percent and 60 percent, respectively.

The American College of Rheumatology published criteria for diagnosing FM with a carefully taken history and a physical examination, without the need for specialized training. The criteria include a Widespread Pain Index and a Symptom Severity Index. The initial workup should include a CBC, BMP, and UA, as well as a thyroid screen to rule out hypothyroidism. Low levels of vitamin D, vitamin B-12, iron, or magnesium should be ruled out. Imaging modalities are not necessary in the diagnosis of FM.

FM is best managed using a patient-centered, multidisciplinary approach initiated in the primary care setting. Acknowledging the disease and showing empathy to patients suffering from FM is important. Patients should understand that FM is a chronic condition that requires long-term management.

Important nonpharmacologic therapies include education on good sleep hygiene and a customized exercise plan. Patients should be encouraged to gradually increase the amount of time that they exercise. Drug monotherapy should be initiated if the nonpharmacologic approach is not sufficient. Medications that have shown efficacy for chronic pain include antidepressants and anticonvulsants. Tricyclic antidepressants are usually initiated first at a low dose taken at bedtime and titrated up as tolerated. They are effective at reducing pain, fatigue and sleep disturbances. Most FM patients are started on amitriptyline, but desipramine has fewer anticholinergic side effects and less cardiotoxicity. For patients with moderate symptoms, cyclobenzaprine may be an acceptable alternative, but it has minimal antidepressant effect. Patients who do not respond to tricyclics or who have depression may benefit from selective serotonin and norepinephrine reuptake inhibitors. Duloxetine and milnacipran are approved for FM.

Anticonvulsants that have shown benefits for chronic pain include gabapentin and pregabalin; they are also preferred in patients with severe sleep problems. Nonsteroidal anti-inflammatory drugs and acetaminophen have not been shown to be very effective for FM chronic pain but can be used to manage acute flareups or nociceptive pain from comorbidities such as arthritis. Tramadol is the only analgesic that has been shown to effectively improve FM chronic pain. 

If symptoms persist with a single pharmacotherapy at the highest dose tolerated by the patient, a combination of drugs should be considered. Patients should also be referred to a rheumatologist or to other specialists to manage a complex drug regimen or comorbidities. Depression should be treated aggressively, and patients should see a psychiatrist or may benefit from psychological intervention, including cognitive behavioral therapy. Additional treatments that can be considered include trigger point injections, acupuncture, physical therapy, and chiropractic treatment.