MKSAP Quiz: 3-year history of pain in muscles, joints
A 47-year-old woman is evaluated for a 3-year history of pain in all of her muscles and joints. She is a commercial truck driver. Her sleep is poor, and she awakens unrefreshed. She completes a fibromyalgia diagnostic questionnaire and meets the criteria for fibromyalgia. She has anxiety and depression. Following a physical exam and lab results, what is the most appropriate treatment?
A 47-year-old woman is evaluated for a 3-year history of pain in all of her muscles and joints. She is a commercial truck driver. Her sleep is poor, and she awakens unrefreshed. She completes a fibromyalgia diagnostic questionnaire and meets the criteria for fibromyalgia. She has anxiety and depression, with a history of opioid use disorder. She takes no medications.
On physical examination, vital signs are normal. Physical examination findings are limited to widespread muscle tenderness with normal strength.
Laboratory evaluation reveals an erythrocyte sedimentation rate of 19 mm/h, a blood C-reactive protein level of 0.3 mg/dL (3 mg/L), and a thyroid-stimulating hormone level of 1.6 μU/mL (1.6 mU/L).
Low-impact aerobic exercise is recommended.
Which of the following is the most appropriate additional treatment?
A. Amitriptyline
B. Diclofenac
C. Duloxetine
D. Pregabalin
E. Tramadol
MKSAP Answer and Critique
The correct answer is C. Duloxetine. This content is available to MKSAP 19 subscribers as Question 40 in the Rheumatology section. More information about MKSAP is available online.
The most appropriate treatment is duloxetine (Option C). In addition to discussing the diagnosis at length and providing education regarding nonpharmacologic recommendations, such as low-impact aerobic exercise, a medication is warranted. Choice of pharmacologic therapy is based on symptom profile, patient comorbidities, and medication adverse effects because few trials have directly compared the efficacy of medications. Of the available choices, duloxetine (a serotonin-norepinephrine reuptake inhibitor) is most appropriate for a patient with fibromyalgia and comorbid depression and anxiety because it is FDA approved for these indications as well. Duloxetine should be started at 30 mg/d and titrated to 60 mg/d after a week or so to mitigate nausea, a frequent early adverse effect that usually dissipates over time. If the drug is stopped, a slow taper should be used because withdrawal symptoms often occur with sudden discontinuation. Patients should be made aware that benefits of the medication will not be seen for several weeks. To measure interval improvement, the Fibromyalgia Impact Questionnaire (a validated clinical tool) or other validated clinical tool should be completed before and an appropriate time after an intervention to assess change in clinical status.
Although amitriptyline (Option A) is an acceptable off-label therapy for fibromyalgia, it is sedating and not appropriate for someone with a job such as truck driving. Amitriptyline is not an effective antidepressant at the low doses recommended for fibromyalgia.
Diclofenac (Option B) is an NSAID. Anti-inflammatory medications, including NSAIDs and glucocorticoids, are not more effective than placebo in treating fibromyalgia.
Pregabalin (Option D), although an FDA-approved medication for fibromyalgia, is not the best option for someone with a physically hazardous occupation because both sedation and dizziness are frequent adverse effects. Pregabalin would also not address this patient's depression or anxiety.
Although tramadol (Option E) is helpful for treating fibromyalgia in the short term, prescribing an opioid is inappropriate in a patient with a history of opioid use disorder or someone with a job that requires a constant state of alertness.
Key Points
- Choice of pharmacologic therapy for fibromyalgia is based on symptom profile, patient comorbidities, and medication adverse effects.
- Duloxetine is appropriate for a patient with fibromyalgia and comorbid depression and anxiety because it is approved for these indications as well.