CARE GUIDE SUGGESTED PROCESS

Transcription

CARE GUIDE SUGGESTED PROCESS
CARE GUIDE for Fibromyalgia
SUGGESTED
GUIDELINES
PROCESS
IMPORTANT FINDINGS
MEASUREMENTS AND VALUES
INTERVENTION
FOLLOW-UP
Confirm Diagnosis
History of chronic pain
> 3 months
The American Pain Society (APS) proposes the
following objective criteria for the diagnosis of
fibromyalgia:
 Widespread pain for at least 3 consecutive months
- all of the following are present:
 pain in the left side of the body
 pain in the right side of the body
 pain above the waist
 pain below the waist
 In addition, axial skeletal pain (cervical spine or
anterior chest or thoracic spine or low back) must
be present
Use a pressure algometer (dolorimeter) to
determine pressure pain thresholds at both lateral
epicondyles and the midpoints of the trapezii to
aid in diagnosis and assess response to therapy.
An abnormal test produces pain at less than 4
kg/cm2 of pressure.

Pain in 11 of 18 tender point sites on digital
palpation

Diagnostic tests to rule out other conditions –
Complete Blood Count (CBC), Thyroid
Stimulating Hormone (TSH), comprehensive
metabolic panel- including uric acid, Creatine
Phosphokinase test (CPK), Erythrocyte
Sedimentation Rate (ESR), C-Reactive Protein
(CRP), Antinuclear Antibody (ANA), anti-cyclic
citrullinated peptide (anti-CCP) antibody, and
rheumatoid factor. Hepatitis-C testing, sleep
studies, 25-hydroxyvitamin D, transferrin, and
pseudogout studies if indicated by history or
preliminary lab results

Psychological screening tests if indicated: e.g.,


1-6, 8)
2013 Fibromyalgia Care Guide FINAL 8/2013
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Begin treatment with
pharmacologic and
non-pharmacologic therapies
Monitor over time
to assess treatment
progress
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SUGGESTED
GUIDELINES
Pharmacologic
Management (1, 3, 4, 5 ,7, 8,
9,10)
PROCESS

Prescribe
medication based on
individual
symptoms and
functional status
2013 Fibromyalgia Care Guide FINAL 8/2013
Healthways Science and Medical Integrity
IMPORTANT FINDINGS
MEASUREMENTS AND VALUES
the Minnesota Multiphasic Personality Inventory,
the Social Support Questionnaire, the Sickness
Impact Profile, or the Multidimensional Pain
Inventory (MPI)
The American College of Rheumatology (ACR)
proposes subjective diagnostic criteria. This criteria
may be found in the ACR journal Arthritis Care &
Research, Vol. 62, No. 5, May 2010, pp 600–610 DOI
0.1002/acr.20140

Functional status, visual analog scale for pain
intensity, degree of fatigue and global selfassessment may be evaluated and quantified using
tools such as the Fibromyalgia Impact
Questionnaire Revised (FIQR) available at:
http://www.myalgia.com/FIQR.info
INTERVENTION
FOLLOW-UP
Medication efficacy:

Strong evidence
 Amitriptyline: often helps
sleep and overall well-being;
dose 25-50 mg
 Cyclobenzaprine 10-30 mg
at bedtime

Modest evidence
 Selective Serotonin Reuptake Inhibitor (SSRI)
 Serotonin Norepinephrine
Re-uptake Inhibitor (SNRI)
 Some anti-convulsants,
including gabapentin

Newly approved for
fibromyalgia:
 Pregabalin (Lyrica) 300 or
450 mg per day for pain
 Duloxetine (Cymbalta) 30
mg/once a day x 1 week,
then increase to 60 mg/once
a day
 Milnacipran (Savella) 50 mg
bid titrated over 1 week
Other individual provider approaches
to the treatment of fibromyalgia may
include any of the following: topical
lidocaine or topical capsaicin,

Re-evaluate and
change medication
plan as needed
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SUGGESTED
GUIDELINES
Non-Pharmacologic
PROCESS
4)
Immunizations (11)
INTERVENTION
tramadol, propranolol at bedtime,
clonidine, increased potassium intake,
rolaxifene, modafinil, or pramipexole
(under investigation)
NOTE: See FDA black box warnings
for suicidality in children, adolescents
and young adults (18-24 yrs) for
antidepressants and secondary to antiepileptics

Strong Evidence
 Cardiovascular exercise
 Cognitive Behavioral
Therapy
 Patient Education
 Multidisciplinary
(combinations of above)

Moderate Evidence
 Strength Training
 Acupuncture
 Hypnotherapy
 Biofeedback
 Balneotherapy

Refer to rheumatologist, pain
specialist, physiatrist, or
psychiatrist

Start concurrently
with medication
management

None

Refer to specialist(s)

Patients not responding to therapy

Influenza
Vaccination

Document patient has an influenza vaccination
each year and document if adverse event occurs


Pneumonia
Vaccination

Document patient has received a pneumonia
vaccination and document if adverse event occurs

(1, 4, 5)
Referral (3,
IMPORTANT FINDINGS
MEASUREMENTS AND VALUES
2013 Fibromyalgia Care Guide FINAL 8/2013
Healthways Science and Medical Integrity
FOLLOW-UP

Begin one or more
therapies and add
additional as
needed

Coordinate care
and monitor patient
progress as needed
Administer vaccination yearly

Yearly
Administer pneumonia
vaccination to all patients once
between 19-64 years of age, with
a booster given to those who are
age 65 and older, if at least 5
years have passed since their
previous vaccine

As indicated
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These guidelines are intended as an educational reference and not as a substitute for the clinical judgment of the treating physician concerning appropriate and
necessary care for a specific patient. These guidelines are based on the clinical references listed at the end of the document. Note that a specific treatment or
therapy listed may not be a covered benefit for all individuals. Please check the individual’s eligibility and benefits plan.
Reference List
1. Buckhardt CS, Goldenberg D Crofford L Gerwin R Gowens S Jackson
K Kugel P McCarberg W Rudin N Schanberg L Taylor AG Taylor J Turk
D. Guideline for the management of fibromyalgia syndrome pain in
adults and children. American Pain Society (APS); (2005), -109. 2007.
3-10-2007. [Buckhardt CS, Fibromyalgia Guideline] Reviewed 5/28/13
2. Gerwin RD. A review of myofascial pain and fibromyalgia--factors that
promote their persistence. Acupunct Med. 2005;23:121-34. [Gerwin RD,
Acupuncture 2006] Reviewed 5/28/13
3. University of Texas, School of Nursing, Family Nurse Practitioner
Program. Management of fibromyalgia syndrome in adults. Austin (TX):
University of Texas, School of Nursing; 2009 Austin, Texas. [University
of Texas, Fibromyalgia Treatment Guideline] Reviewed 5/28/13
4. Hassett AL, Gevirtz RN, Nonpharmacologic Treatment for
Fibromyalgia: Patient Education, Cognitive-Behavioral Therapy,
Relaxation Techniques, and Complementary and Alternative Medicine.
Rheumatic Disease Clinics of America. 35 (2009) 292-407. Reviewed
5/28/13
6. Wolfe F, Clauw D, Fitzcharles M, Goldenberg D, Katz R, Mease P, et
al. The American College of Rheumatology Preliminary Diagnostic
Criteria for Fibromyalgia and Measurement of Symptom Severity. 2010
American College of Rheumatology: Vol 62, No.5, May 2010
pp 600-610 Reviewed 5/28/13
8. Boomershine CS, Crofford, LJ. A symptom based approach to
pharmacologic management of fibromyalgia. Nat. Rev. Rheumatol. 5,
191-100 (2009); doi:10.1038/nrrheum.2009.25 Reviewed 5/28/13
5. American Academy of Family Physicians. Fibromyalgia in Family
Medicine: Challenges in Pain Management, 2011 American Academy of
Family Physicians – Pain Management Series Reviewed 5/28/13
http://www.aafplearninglink.org/index.aspx
7. Bennett RM, Friend R, Jones KD, Ward R, Han BH, Ross RL. The
Revised Fibromyalgia Impact Questionnaire (FIQR): Validation and
Psychometric Properties. Arthritis Research & Therapy.
2009;11(4):R120. Reviewed 5/28/13
9. FDA Proposes New Warnings About Suicidal Thinking, Behavior in
Young Adults Who Take Antidepressant Medications. FDA. 2007. 7-62007. [FDA Warning: Antidepressants] Reviewed 5/28/13
10. FDA. Information for Healthcare Professionals Suicidality and
Antiepileptic Drugs. FDA. 1-31-2008. 2-7-2008. Updated 12-16-2008
[FDA – Antiepileptic Drugs] Reviewed 5/28/13
11. Recommended Adult Immunization Schedule. MMWR January 28,
2013, Vol. 62 http://www.cdc.gov/mmwr/pdf/wk/mm62e0128.pdf
2013 Fibromyalgia Care Guide FINAL 8/2013
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