A 35-year-old woman complains of aching all over. She sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports that she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and ESR are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient?
The patient's multiple tender points, associated sleep disturbance, and lack of joint or muscle findings make fibromyalgia a likely diagnosis. Patients with fibromyalgia often report dropping things due to pain and weakness, but objective muscle weakness is not present on examination. The diagnosis hinges on the presence of multiple tender points in the absence of any other disease likely to cause musculoskeletal symptoms. CBC and ESR are characteristically normal. Cognitive behavioral therapy and graded aerobic exercise programs have been demonstrated to relieve symptoms. Tricyclic antidepressants are considered if medication is needed and may help restore sleep. Cyclobenzaprine is a next step medication. If both of those fail, then a trial of gabapentin, pregabalin, or duloxetine can be undertaken. Aspirin, other anti-inflammatory drugs (including corticosteroids), and DMARDs (such as methotrexate or hydroxychloroquine) are not helpful, nor are simple stretching/flexibility exercises. Of note, rheumatoid factor and ANAs occur in a small number of normal individuals. They are more frequent in women and increase in frequency with age. It is not uncommon for an individual with fibromyalgia and an incidentally positive RF or ANA to be misdiagnosed as having collagen vascular disease. Therefore, it is necessary to be careful to separate subjective tenderness on examination from objective musculoskeletal findings and to assiduously search for other criteria before diagnosing RA, SLE, or other collagen vascular disease.
Graded aerobic exercise
Prednisone
Weekly methotrexate
Hydroxychloroquine
Immunology and Rheumatology