Q&A Medicine>>>>>Rheumatology
Question 5#

A 43-year-old woman presents with chronic pain that she describes as occurring “all over her body.” Any movement exacerbates the pain and she reports much difficulty falling asleep at night. She constantly feels fatigued, but she denies fever, weight loss, or obvious muscle weakness. The patient has tried acetaminophen to no avail and has even attempted to run 1 to 2 miles per day with no improvement in her symptoms. The patient has an insignificant past medical history. Physical examination is significant for tenderness to palpation over several specific locations on her body. Neurologic examination is unremarkable and laboratory results are all within normal limits.

Given this patient’s most likely diagnosis, which of the following is the best initial treatment?

a. Prednisone
b. Naproxen
c. Amitriptyline
d. Colchicine

Correct Answer is C

Comment:

Amitriptyline. The patient in this question is presenting with signs and symptoms consistent with a diagnosis of fibromyalgia (FM). FM is more common in middle-aged women and is characterized by chronic widespread pain and allodynia (a heightened and painful response to pressure). Physical examination is typically normal except for point muscle tenderness in several areas including the mid-trapezius, lateral epicondyle, and greater trochanter, among others. Of note, FM has no laboratory findings that are diagnostic of the condition. The first-line treatment for FM is patient education, aerobic exercise, and good sleep hygiene. This patient has clearly attempted those recommendations based on the history she provides, so the first-line medication is a tricyclic antidepressant (TCA) such as amitriptyline. Several other drugs (pregabalin and duloxetine) can be attempted if TCAs fail to alleviate the patient’s symptoms. (A, B) Corticosteroids and NSAIDs are useful in treating inflammatory conditions, but FM is not an inflammatory condition (not associated with elevated inflammatory markers such as ESR). (D) Colchicine is useful in treating gout, not FM.