Benjamin Natelson, MD

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: 

In our last couple of questions, gentlemen, how can we, me as a primary care provider, and you, as my specialty colleagues- how can we work together, do you think, to help improve the care of these patients with fibro?

Have a full network of occupational therapists, physical therapists, mental health, in addition to some specialists in neurology and pain management.

And we need to encourage our third party payers to more broadly reimburse for these integrative therapies. It's so much easier to take care of someone with fibromyalgia when, again, they're getting cognitive behavioral therapy for insomnia and they're getting a little bit of acupressure and there's other providers and other people attending to them, and the evidence base for these therapies has really increased to the point now that they really should be broadly approved for almost any type of chronic pain.

And I would just add that all 11 nurse practitioners that work for me in my clinic, we read every note that you send in to us from the specialty, because we all learn a lot from the way you have set the bar and the education that you do in your consult notes, I just think that's just really important to keep up setting that bar with–because you have access to some of that latest information on the latest guidelines and treatments. As we're wrapping up tonight because our time has come to end this. This conversation has been so incredibly rich and informative. I've learned so much from all of you tonight and I want to thank you. But before we conclude this program, I'd like to ask each one of you to issue just a final thought that you have for our audience tonight. Dr Botsoglou, can you go first for us?

I just would like to share that this is a disease that is primarily seen in the primary care setting and with a multi-specialty approach and using modalities like aqua therapy, physical therapy, occupational therapy, in addition to pharmacologic therapy, we will be able to identify and treat these patients earlier and lead to less disease and morbidity.

Yes, just to segue, I really think one of the biggest problems of taking care of individuals with conditions like fibromyalgia, is we wait too long before we diagnose and start treating them. If we waited seven to eight years to take care of–start treating rheumatoid arthritis, those people wouldn't have any viable joints left or gout or something like that or heart disease, so I think that that long wait–especially people that are taking care of adolescents and individuals in their 20's, you can see fibromyalgia coming when these people start having these different pain conditions in different areas of their body. When that happens, these people should be aggressively treated then, rather than ignored and acted as if there is nothing wrong with them.

Again, like you pointed out earlier, giving the patient the diagnosis and establishing a good doctor-patient relation with good rapport leads to improved quality of life in and of itself. And then, putting the patient on the same page with you in terms of treatment and expectation, I think we can promise we will help them. But as you pointed out, Wendy, we're not going to be able to cure them. But if we emphasize that we can help them and they can do better and they can help themselves with gentle physical conditioning and some of the other things that were mentioned, which are non-medical, that's our job as doctors.

I agree, and I would just like to add that having a relationship with a primary care provider or with a specialist who believes that there truly is something wrong. As I often say to my patients, just because we don't have a lab test to diagnosis it or an imaging study to do, doesn't mean that this doesn't exist and so, giving them that diagnosis and forming a partnership with them, but not just focusing on pain, but also focusing on sleep and function can go a long way to improving their quality of life. It's been such a great evening and I thank you for watching this peer exchange. If you enjoyed the content, please subscribe to our newsletters to receive upcoming peer exchanges and other great content right in your inbox. Good night and goodbye for now.

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Experts conclude their discussion emphasizing the importance of integrative care and how providers can improve outcomes for their patients with fibromyalgia (FM).

Prospective Advancements and Final Thoughts on the Treatment of FM

I'm not finding this, but I'm wondering if any of you are. Given that many of these medications are now generic, not all of them. But are there challenges in getting these medications covered by payers at this point? We heard earlier that, for instance, the Orexin Antagonists for sleep, we must often have a prior authorization done. But what about the medicines, Milnacipran? Are you seeing any issues? Duloxetine? Pregabalin? Gabapentin? Getting these drugs approved?

One reason why I select Gabapentin first is that I know I don't have to get it approved. It's so widely available and affordable. But if you want to transition to Pregabalin you must show–a prior authorization is required and you do have to demonstrate failure at least with a therapeutic dose of Gabapentin.

What do you think the biggest challenges are in terms of unmet needs for our patients with fibromyalgia?

Treatment and I guess my colleagues see patients on the severely ill end of that skewed spectrum and I'd like not to have to use an opioid so if there was anything that I could put in after I ramp up. I have this ramp up schedule, so if I didn't have to go to opioids, I'd love to have that tool.

The problem as I see it is we need to train a new group of providers to take care of people with chronic pain. The people that hang out a shingle in the United States as pain management have usually got a one-year fellowship to put needles into people. We really need people, providers to embrace the fact that in the right settings where they can provide integrative care, where they're not out on an island taking care of individuals on their own. Where they have more of a village. They can put someone in. In those systems, these patients get better. They're a lot easier to care for. But if you're a single, individual provider, who's trying to do this on your own, good luck.

In addition, having our primary care providers feel more comfortable and realize this doesn't have to be a specialist. This is something they see more often. They have the same tools that we have and it's something that can be easily treated rather than cycling through a variety of specialists and ultimately a delayed diagnosis, because as we mentioned, sometimes the diagnosis itself can be therapeutic for the patient.

Experts highlight current challenges in their practice treating patients with fibromyalgia (FM).

Challenges and Unmet Needs in FM

Individualizing fibromyalgia treatment, we've talked about this. We've talked about not ignoring the sleep issue. What is your first go to sleep agent? Is there one that you–I heard cyclobenzaprine. I heard amitriptyline. Are you using the z drugs? Are you using benzos? What are you all doing to help people sleep?

Xyrem. Oxybate. I find it useful. It's very short acting. A patient may wake in the middle of the night and take a second dose, but because it's so heavily controlled, I don't know how common it will be for the primary care provider. Usually, these sleep medicines put you to sleep, but the patient still reports that they're unrefreshed. And those early studies on Oxybate and FM suggested that it did relieve pain and so that's why I tried it.

But think of Gabapentinoids as hypnotics as well. There were studies that were done showing that about 40, 45% of the benefit of Pregabalin in the fibromyalgia registration trials seemed to be through an improvement in sleep, and people are unaware that although Pregabalin and Gabapentin, when they were approved, were approved as TID, BID drugs. There's a lot of evidence that for pain, the main benefit is to give them a bedtime and that hypnotic affect. And you get a lot of adverse effects by giving people Pregabalin or Gabapentin dose in the morning, but you don't get much benefit from that. I will usually just use a single nighttime dose of a Gabapentinoid and push it up, because you get a lot of side effects from that morning dose that you don't need.

When you ask someone with fibromyalgia, who also has a concomitant depression or anxiety, do you use Milnacipran because it's sister drug, Levomilnacipran, is approved for depression? It's an SNRI. Do any of you use Milnacipran and Duloxetine to try to optimize both pain, as well as depression and anxiety, or do you combine?

I use Lamotrigine, which psychiatrists use all the time for mood control. Lamotrigine or Lamictal. I find that drug helpful at moderately high doses and I am willing to try any anti-epileptic drug to see if they'll help pain by reducing the central sensitization process.

I haven't heard you mention Topiramate. Is that in your armamentarium at all?

Just for headaches. I don't like that. I don't use that drug often.

I agree with Dan. Starting with Gabapentin at night. That's my go to. Also, just because it's easy to obtain and start. And then start a mid-day dose later, but to start at night, especially for sleep.

600 mg and then go to 900 mg at night. If that doesn't achieve relief during the daytime, I will start on very low doses. With Gabapentin, I start really with 100 mg in the day, and then ramp up from that, but 600 mg–I don't start with 600 mg at night. I start at 300 mg, then double it and put it up to 900 mg, but then I would use 100 mg doses twice during the day and see whether you can't ramp up without adverse effects. I can do it, but some patients can't tolerate it.

Experts discuss how they personalize treatments for patients with fibromyalgia (FM) and the importance of improving sleep in their approach. 

Personalizing FM Treatment

What do you think about combining therapies? We've already talked about using something like a duloxetine with gabapentin. What are your typical combination therapies and what does the evidence show? Is there any evidence out there showing efficacy?

There's no evidence on efficacy of multiple anti-epileptic, that's for sure. All this is empiric. The practice of medicine is very empiric still. I mean we have FDA approved medicines, but if a patient is still suffering, we can do one of two things. Tell them what I can do for them or try something else. I'm willing to try other medicines and try to personalize it to the patient as much as I can, but sometimes you really are unable to help the patient despite your best efforts.

I also like to set the expectations with the patients and advise them. These are the options we have. We'll start here. We'll work our way up. I also give them some realistic expectations that if we don't reach these goals, I may have to send you out elsewhere.

One of the things for me that I feel like is important as I'm working with my patients is setting that realistic goal that I'm not going to cure your pain. You're not going to go to a pain level of zero. But if I can reduce your pain by 30% as we add on and augment and combine these different therapies, that's what I'm looking to do. It's to see if I can get you to a more functional, and I'll use a functional tool, like a brief pain index to see if I'm improving their function, in addition to reducing their pain. Those are the things that I try to do because we did our patients a disservice when we said we're going to cure your pain.

And we're not going to cure their pain. We're going to mitigate their pain and hopefully improve their overall quality of life and their function.

In the pain field, for some time, there's been a focus more on improving function and getting people to attend to that. Also, to be aware that it can be highly motivating to a patient to ask them what are 1 or 2 things that your pain is precluding you from doing right now that you'd like to be able to do. You'd like to play nine holes of golf or be able to pick up your grandchild or whatever. Those personally meaningful functional goals are often very motivating for patients. Way more so than their VAS pain score going from a 6 to a 3, which we might care about, but they don't care at all about. They care about what they can do, so that's–I think in practice, if you're not trained in pain, sometimes you attend too much to the pain and not enough to the what is someone functionally unable to do and how can we help motivate them to do better.

Experts discuss the limited combination therapy options for the treatment of fibromyalgia (FM) and how to inform patients of prospective outcomes.

Benjamin Natelson, MD

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