A 35-year-old pharmacist complains of "hurting all over." Her pain is particularly bad in her upper back and shoulders, and she notes morning stiffness. On examination, her joints are not inflamed, but she has symmetric "tender points" in the posterior neck, anterior chest, lateral buttocks, medial knees, and lateral elbows. You make a preliminary diagnosis of fibromyalgia.
Which of the following is the most appropriate therapeutic recommendation?
- avoid most physical activity
- trial of amoxicillin
- benzodiazepine in low doses for sleep
- low-dose steroid
- low-dose antidepressant
Answer(s): E
Explanation:
Sleep disturbance is a characteristic symptom associated with fibromyalgia. Patients awaken feeling tired.
The examination, other than tenderness in 14 specific, symmetrical points, is usually normal. Fever, rash on the extremities, muscle weakness, and migratory joint inflammation point to Lyme disease or other rheumatologic disorders. Asedimentation rate should be normal. If elevated, it may point to another diagnosis. Lyme titers are not indicated unless the patient has symptoms or history suggestive of the disease. Electromyelography and spine radiographs are typically normal and unnecessary for help in establishing the diagnosis.
Depression can be associated with pain, but screening for it early on does not make sense and might offend the patient. Low-dose antidepressants often help to correct the sleep pattern and result in relief of pain. Nonsteroidal anti-inflammatory agents can also be used as needed; low-dose steroid is not indicated.
Exercise is also helpful, and patients should be encouraged to stay physically active. Amoxicillin is not used for fibromyalgia. Benzodiazepines have addictive potential and lose their effectiveness for sleep after a few weeks.