Jan 15, 2013

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy


As usual, my daughter Emily was very excited about her birthday this year. As it happened, the school ski trip to Assessippi Ski Resort fell on her birthday and she was very excited to try downhill skiing for the first time. Emily was excited to FaceTime with her cousin in Winnipeg and Aunt in Langley, BC. She seemed to be most excited about her age, though. Emily figured out that since she was now the oldest kid in her grade five class that next year she would be the oldest kids in all of Ecole McNeill. Its funny how the things we get excited about change over time. I cant think of the last time I was excited about my advancing age being acknowledged, or the last time I was excited to be the oldest in some group. I would get a little upset if I was announced to be the oldest person in a room.


Ive been a geek for a long time, and I still get pumped when I learn new facts. I remember being excited when I learned the term diagnosis of exclusion. It was in reference to fibromyalgia. I was told that in fibromyalgia, doctors exclude every other cause of a persons pain and if they cant find another cause, they call it fibromyalgia. I thought that was pretty cool. However, fibromyalgia patients were less excited about being called a diagnosis of exclusion. To patients, diagnosis of exclusion sounds like the doctor is saying their pain is all in their head.


Patients with fibromyalgia usually go to the doctor with saying things like I hurt all over or It feels like I always have the flu. These symptoms will have lasted over 3 months. Fibromyalgia or FM patients will also complain of fatigue all the time. The FM patient will often have sleep problems and may complain of depression, anxiety, irritable bowel syndrome, irritable bladders and other problems. The doctor will generally check over the patient and see if there are any reasons for the fatigue or the pain. The doctor will also probably check for tender points both above and below the waist line. Usually if a patient has 11 of these 18 tender points, the doctor can be fairly certain the patient has fibromyalgia.


What causes fibromyalgia? We dont know. But, it is not an imaginary illness. We used to think it was a problem with the muscles themselves. Now most researchers think the muscle problems in fibromyalgia are because the muscles are inactive due to pain. So the pain causes the patient not the move and that cause the muscle problems. Researchers now think FM is caused by the body not processing pain signals properly. There is some evidence that FM runs in families so it might have a genetic component. But it is probably a combination of genes and environment that make some peoples nervous systems hypersenistive to pain signals.


How is fibromyalgia treated? Your doctor will probably start by talking about sleep and exercise. Many people with fibromyalgia also have sleep problems. The doctor will probably encourage good sleep hygiene. Good sleep hygiene includes things like going to bed and getting up at the same time every day, no computers, iPads or any other screens in the bedroom, keeping the bedroom quiet and dark and avoiding naps during the day. Exercise may seem counter-intuitive to someone who is sore and tired all the time, but exercise has many potential benefits. Exercise during the day will help with sleep at night. Some of the muscle problems of fibromyalgia are due to muscle inactivity. Aerobic exercise like fast walking, biking, swimming and water aerobics have all been studied as treatments for FM.


Improvements in sleep and exercise wont help everyone completely. So in addition to sleep and exercise, your doctor might talk about medications to treat FM. Often the patient themselves will already be using acetaminophen or Tylenol at home. There isnt much evidence saying acetaminophen will help FM. You also have to be careful not to take more than the equivalent of 6 tablets of extra strength Tylenol per day. Your doctor may decide to try pain killers like codeine or tramadol for moderate or severe pain.


Usually the first medication you doctor will reach for in FM is amitriptyline. Amitriptyline is a tricyclic antidepressant. It is relatively inexpensive and it may help with sleep and mood as well as pain. Amitriptyline can cause drowsiness, weight gain and dry mouth. If amitriptyline doesnt work, your doctor may reach for duloxetine. It is a newer drug, so it is much more expensive, but it is approved to treat fibromyalgia. Duloxetine is called a SNRI or serotonin norepinephrine reuptake inhibitor. It has side effects like nausea, headache, dry mouth and insomnia. If duloxetine is too expensive, your doctor may try an older SNRI like venlafaxine. Because it is a little more stimulating, some doctors choose SNRIs for FM patients whose main concern is fatigue. Pregabalin is another Health Canada approved treatment for fibromyalgia. It was developed by chemically altering the anti-seizure medication gabapentin. It can have side effects like cognitive impairment, weight gain and swelling. Because it is a new drug it is also expensive. If pregabalin is too expensive, the doctor may choose the older drug gabapentin instead. Because pregabablin and gabapentin are more sedating, some doctors use them in FM patients whose main concern is trouble sleeping.


Im sorry I used to refer to fibromyalgia as a diagnosis of exclusion. There are actual symptoms doctors look for to diagnose fibromyalgia and we dont call it a diagnosis of exclusion anymore. Researchers are looking for genetic causes of fibromyalgia and brain changes in these patients. It is a real condition. Im glad Emily is still excited about her birthday. However, I still dont think Ill be excited if someone announces to a group that Im the oldest person in the room.



As always if you have any questions or concerns about these or other products, ask your pharmacist



The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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