FM Patient Case Study: Mrs C

Applying multimodal therapy: part 1

You decide to start Mrs C on an approved pharmacotherapy for FM, based on her symptom profile. When you prescribe this medication, you discuss her expectations, explaining that medications used in FM management are not cures, but they can help reduce FM pain and improve function. You explain that every person is different and that it may take some trial and error to determine if the chosen medication works and at which dose. You describe possible side effects and explain that at first she may feel these effects before she experiences relief—which may take several weeks. You encourage her to stick with it through this initial period because she needs to give the therapy time to work, and side effects may resolve as her body gets used to the drug. You start at a low dose to minimize side effects, with a plan to slowly titrate upward as needed to achieve therapeutic efficacy. Mrs C’s pretreatment pain score was 7. Slight decreases in this score are observed after the initiation of therapy (eg, pain score of 6 after 2 months), but more reductions may require upward dose titration.

You assess Mrs C’s fitness level, ask what activities she prefers, and together come up with a plan for her to walk 10-15 minutes a day and to gradually increase the time as she feels able. You write all this clearly on a prescription pad to emphasize its importance as part of the treatment plan to reach the first goal she has set (hosting a play date).

You also decide to refer Mrs C to a sleep specialist to determine whether she has sleep apnea. You explain to Mrs C that if she has sleep apnea, it can be treated and may help with her sleep and fatigue, which are major problems for her. Meanwhile, you discuss sleep hygiene and provide a handout with tips for her to take home.

To help build Mrs C’s self-management skills you talk with her about the importance of activity pacing. You stress that the key to living with any chronic condition is to learn ways that one can control it and suggest she visit a website that offers a self-management program for people with FM, which she agrees to do. You remind her of the goals she has agreed to and ask her to schedule a follow-up visit.

In the interim, Mrs C schedules an appointment with a sleep specialist, who diagnoses her with sleep apnea after a sleep study. Mrs C uses a continuous positive airway pressure (CPAP) device for a week and notes that, after getting used to the device, she seems to be sleeping more soundly and waking up feeling more refreshed.

In addition to being seen by a sleep specialist, Mrs C continues to have her interstitial cystitis managed by a urologist.

patient picture

Treatment plan

  • Patient started on approved pharmacotherapy for FM

  • Review of expectations

  • Discussion of possible side effects

  • Need to titrate dose

  • "Prescription" for physical activity (eg, walk 10-15 minutes/day)

  • Referral to a sleep specialist for possible sleep apnea

Build self-management skills

  • Stress importance of activity pacing

  • Refer to online self-management program for FM

  • Reinforce goals

Sleep specialist outcomes

  • Sleep apnea diagnosed

  • CPAP trial completed, some improvement noted

Urologist outcome

  • Ongoing management of interstitial cystitis