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Fibromyalgia (chronic primary pain) — SCE Rheumatology MCQ

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ModeratePain ManagementFibromyalgia (chronic primary pain)SCE Rheumatology

A 46-year-old woman has an 18-month history of generalised musculoskeletal pain, fatigue, unrefreshing sleep and impaired concentration. Examination shows widespread tenderness but no synovitis, enthesitis, muscle weakness or focal neurological abnormality. Full blood count, creatine kinase, thyroid function, calcium, C-reactive protein and erythrocyte sedimentation rate are normal. Fibromyalgia, classified for management purposes as chronic primary pain, is diagnosed. She has completed a supervised aerobic and strengthening programme and cognitive behavioural therapy for pain, with improved function but persistent troublesome pain and sleep disturbance. She does not have depression and is not taking analgesics. There is no anticholinergic contraindication. Following discussion of off-label treatment, which medicine is most appropriate to initiate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Amitriptyline

Explanation lettering: C = shown as A · A = shown as B · B = shown as C · E = shown as D · D = shown as E

This presentation is consistent with fibromyalgia and hence chronic primary pain: symptoms are generalised, investigations and examination provide no adequate inflammatory, structural or neurological explanation, and appropriate non-pharmacological measures have already been undertaken. NICE recommends considering a specified antidepressant, including amitriptyline, after discussion of benefits and harms. Such treatment may improve pain, sleep, quality of life and psychological distress even without depression. Amitriptyline is particularly reasonable here because sleep disturbance remains prominent and there is no stated anticholinergic contraindication. Gabapentin (A) and pregabalin (C) may appear attractive because they are used for neuropathic pain and have featured in fibromyalgia literature, but NICE advises against initiating antiepileptic drugs, including gabapentinoids, for chronic primary pain. There is no distinct neuropathic pain syndrome in this case. Naproxen (B) is inappropriate because there is no inflammatory or nociceptive disorder likely to respond to an NSAID; NICE advises against initiating NSAIDs for chronic primary pain. Tramadol (D) is an opioid and should not be initiated for this indication because sustained benefit is unproven and opioid-related harms may accrue. The absence of depression does not preclude amitriptyline when its pain-related rationale is explained.

Reference: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain — Recommendations (7 April 2021) — https://www.nice.org.uk/guidance/ng193/chapter/recommendations Chronic pain (primary and secondary) in over 16s — Rationale and impact (7 April 2021) — https://www.nice.org.uk/guidance/ng193/chapter/Rationale-and-impact Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain — Recommendation 1.2.10 (7 April 2021) — https://www.nice.org.uk/guidance/ng193/chapter/recommendations