Dr. Giuseppe CAUTELA Specialista in Gastroenterologia ed Endoscopia Digestiva Istruzioni per la preparazione dei pazienti che si sottopongono a Endoscopia del COLON con capsula Alimenti a basso residuo Proibito: Consentito: • Pane (nero, di farina intera, focaccia di granturco, • Riso perlato, tagliatelle, pasta, maccheroni e • Patate con la buccia, riso integ
Homepages.sover.netWhat Your Pharmacist Should Know
adapted from “The Fibromyalgia Advocate” This information may be freely copied and distributed only if unaltered, with complete original content including: Devin Starlanyl, 2008.
Each of us with fibromyalgia (FM) and Chronic Myofascial Pain (CMP) needs a trustworthy pharmacist to coordinate our medications and keep us informed. New medications are coming out so rapidly that it is impossible for physicians to keep up with them all. Our health care team often comprises many specialists, and they don’t always communicate with each other. Most of us are on many medications of different kinds, and people with FM tend to react unusually to medications. Some of our medications can interact unpleasantly. For example, Soma (carisoprodol) can react with niacin if taken at the same time, producing nausea and a painfully hot flush and rash. FM, CMP and MedicationOften, people with FM and CMP have to try many medications before they find the best ones. We react differently to each medication, and there is no “cookbook recipe” for FM or CMP. What works well for one of us can be ineffective for another. A medication that puts one person to sleep may keep another awake. There is a whole subset of FM and CMP patients who find medications such as Benedryl, Ultram, Pamelor, and Paxil stimulating. Some of these people may look healthy, but their suffering can be great. We all have our own unique combination of neurotransmitter disruption and connective tissue disturbance. We need doctors who are willing to stick with us until an acceptable symptom relief level is reached. We also need a compassionate and understanding pharmacist to work with us.
The most-studied medications that modulate neurotransmitters are psychoactive drugs. This does not mean that the patient’s condition is psychological. Fibromyalgia patients have enhanced nociception (Bendtsen, Norregaard, Jensen et al. 1997) and are often in great pain. Medications that affect the central nervous system are appropriate for FM. The target symptoms are sleep lack, muscle rigidity, pain, and fatigue. These medications don’t stop the alpha-wave intrusion into delta-level sleep, but they do extend the amount of sleep, and may ease symptom “flares.” It is the rule rather than the exception that an FM and CMP client will save strong pain medications from a surgery or an injury for when they are really needed—for an FM/CMP “flare.” This behavior indicates that their perpetuating factors are not under control and that their needs are not being met. FM is often misunderstood (Jones 1996) by the medical profession, and your clients may turn to you for guidance and understanding.
Medications and NarcoticsIt’s normal to be depressed by chronic pain, but that doesn’t mean depression is causing the pain. FM is a sensory amplification syndrome (Kosek, Ekholm and Hannson 1996). Maintenance with mild narcotics (Darvocet, Tylenol #3, Vicodin-Lorcet-Lortab) for nonmalignant (noncancerous) chronic pain conditions is a logical, humane alternative if other reasonable attempts at pain control have failed. The main problem with raised dosages of these medications is not with the narcotic components per se, but with the aspirin or acetaminophen that is often compounded with them. There can be serious side effects with NSAID usage (Gardner and Simpkin 1991). Please keep an eye on the level of your client’s medications.
Clients with FM and CMP need adequate pain control to break the pain/contraction/ pain/contraction spiral. It does not serve them well if you treat them like addicts. They get no pleasure from their medications, just some symptom relief. However, the level of medication should not be rising steadily. That is a sign that the perpetuating factors are not being treated properly, and/or that the level of pain relief is not adequately treated with the current medication. During a symptom flare, these clients often need more medications, but the level should decrease again after flare has subsided. Narcotic analgesics are sometimes more easily tolerated than NSAIDs (Reidenberg and Portenoy 1994). Neither FM nor CMP is inflammatory, and anti-inflammatory medications often contribute to malabsorption in the gut. NSAIDs may disrupt stage 4 sleep, and delta sleep is already interrupted in FM. Prolonged use of narcotics may result in physiological changes affecting tolerance or physical dependence (withdrawal), but these are not the same as psychological dependence (addiction).
Be sure to ask your FM and CMP clients about multiple chemical sensitivities. Many of us are lactose intolerant, and can’t deal with even the small amounts of lactose used as fillers in many medications. Be patient. Many of us will appear confused at times, due to “fibrofog.” We need your help to cope with the difficulties of living with an invisible chronic illness.
Bendtsen, L., J. Norregaard, R. Jensen and J. Olesen. 1997. Evidence of qualitatively altered nociception in patients with fibromyalgia. Arth Rheum 40(1):98–102.
Gardner, G. C. and P. A. Simpkin. 1991. Adverse Effects of NSAIDs. Pharm Ther 16:750–754.
Jones, R. C. 1996. Fibromyalgia: misdiagnosed, mistreated and misunderstood? Am Fam Phys 52(1):91–92.
Kosek, E., J. Ekholm and P. Hansson. 1996. Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms. Pain 68(2-3):375–383.
Reidenberg, M. M. and R. K. Portenoy. 1994. The need for an open mind about the treatment of chronic nonmalignant pain. Clin Pharmacol 55(4):367–369.
Via E-mail Harold Van Wart, Ph.D. President and Chief Executive Officer CymaBay Therapeutics, Inc. 3876 Bay Center Place Hayward, CA 94545 CymaBay Therapeutics, Inc. Form 10-12G Filed August 12, 2013 File No. 000-55021 We have reviewed your filing and have the following comments. In some of our comments, we may ask you to provide us with information so we may better understand your