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Category: General

Published on Monday, 11 August 2008 14:19

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Pharmacological management
Patients with fibromyalgia tend to be sensitive/relatively intolerant to medications and, therefore, it is advisable to begin with low doses and to use medications with the least number of side effects.

All medications should be reviewed at regular intervals to monitor their efficacy. Explaining that some side effects, e.g. those associated with tricyclics, may resolve in time can encourage the patient to persist with treatment. Also, some medications can cause weight gain, so less physically active patients may need to be advised to watch their calorie intake.

Pain
Current research points to an effective combination of tramadol hydrochloride and paracetamol (Ultracet).¹⁷ This combination affects both the ascending and descending pain pathways augmenting the release of serotonin and noradrenaline. Other analgesics like co-proxamol, co-codamol and co-dydramol may or may not be effective.

There is limited evidence for the use of anti-inflammatory drugs. Low dose tricyclics, e.g. 10 mg of amitriptyline or dothiepin, and anticonvulsants, e.g. gabapentin or carbamazepine, can also prove effective for neuropathic pain.¹⁸ Muscle relaxants, e.g. baclofen, can be helpful if muscle twitching or cramps accompany the pain.¹⁸

Sleep and fatigue
Re-establishing a successful sleep routine can enhance sleep quality and reduce fatigue, improving the patient’s ability to cope with other symptoms. Low-dose tricyclics, e.g. 10 mg of amitriptyline or dothiepin, can prove most effective.

Tricyclics are preferable to benzodiazepine hypnotics. Benzodiazepines can be useful for initially re-establishing a sleep routine, but should never be used for more than 10–14 days because of a higher risk of psychological and physical dependence with long-term use.

Abdominal symptoms
Irritable bowel syndrome is a very common associated symptom. The use of antispasmodics, e.g. mebeverine or alverine, may reduce the spasm of the hypersensitive bowel.

Some individuals may have an intolerance to wheat and/or dairy products and excess fibre may also exacerbate the symptoms. Advise a well-balanced diet. The addition of good quality probiotics can prove useful for some patients.¹⁹

Depression
Symptoms of depression can also arise from the fear and isolation of living with chronic pain. Depression is rarely the causative factor behind fibromyalgia. Coming to terms with living with fibromyalgia and adopting changes in attitude and lifestyle is often sufficient to deal with depressive symptoms.

It is important to tackle any co-existing factors that may also be contributing to the depression. In persistent cases antidepressants, e.g. tricyclics or selective serotonin reuptake inhibitors (SSRIs), can prove effective. SSRIs can be used to enhance alertness, motivation and elevate mood during the day, reducing the symptoms of fatigue, pain and apathy. SSRIs can cause restlessness and contribute to insomnia and therefore are recommended for morning administration.

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