What are the management options for a patient experiencing a fibromyalgia flare with fever?

Management of Fibromyalgia Flare with Fever

During a fibromyalgia flare with fever, continue the usual dose of fibromyalgia medication and add NSAIDs for symptomatic treatment, while carefully ruling out other causes of fever. 1

Differentiating Between Fibromyalgia Flare and Infection

When a patient with fibromyalgia presents with a flare and fever, it's crucial to determine whether the fever represents:

1. A symptom of the fibromyalgia flare itself
2. A concurrent infection (which fibromyalgia patients are more susceptible to)

Recent evidence shows that fibromyalgia patients have significantly higher incidence of infectious diseases compared to the general population, with increased odds ratios for:

• Respiratory infections (OR = 1.49-1.98)
• Gastrointestinal infections (OR = 1.40-7.88)
• Genitourinary infections (OR = 1.79-3.17)
• Systemic infections like COVID-19 (OR = 1.76) 2

Management Algorithm

Step 1: Assessment

• Check vital signs (temperature, heart rate, blood pressure, respiratory rate)
• Evaluate for localizing symptoms of infection (cough, dysuria, skin changes)
• Order appropriate laboratory tests if infection is suspected:
  • Complete blood count
  • C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)
  • Urinalysis if genitourinary symptoms present
  • Blood cultures if temperature >101°F (38.3°C)

Step 2: Management of Fibromyalgia Symptoms

• Continue usual fibromyalgia medications at regular doses 1
• For pain management during flare:
  • Add NSAIDs for symptomatic relief 1
  • Pregabalin can be maintained at usual dose (300-450 mg/day) 3
  • Avoid opioids as they have not demonstrated benefits for fibromyalgia 4

Step 3: If Infection Is Suspected

• Treat the underlying infection appropriately based on source
• Monitor for medication interactions, particularly with:
  • NSAIDs and antibiotics (renal effects)
  • Pregabalin dosing may need adjustment in renal impairment 3

Step 4: Supportive Care

• Ensure adequate hydration
• Rest during acute phase of flare
• Apply heat or cold therapy to painful areas
• Resume gentle movement as symptoms allow

Medication Considerations

NSAIDs

• First-line for symptomatic treatment during flares 1
• Caution with prolonged use due to gastrointestinal, renal, and cardiovascular side effects
• Examples: ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily

Pregabalin

• Maintain usual dose during flares (300-450 mg/day) 3
• Do not abruptly discontinue during flares
• Dose adjustments may be needed in patients with renal impairment 3

Other Medications

• Duloxetine, milnacipran, or amitriptyline should be continued at usual doses 4
• Avoid adding muscle relaxants unless specifically indicated

Special Considerations

Monitoring

• Follow up within 48-72 hours if fever persists
• Monitor for signs of worsening infection requiring antibiotics
• Assess response to symptomatic treatment

Common Pitfalls to Avoid

1. Attributing all symptoms to fibromyalgia without ruling out infection
2. Discontinuing fibromyalgia medications during flares
3. Overreliance on opioids for pain management
4. Failing to recognize that fibromyalgia patients have higher susceptibility to infections 2

When to Seek Emergency Care

• Fever >103°F (39.4°C)
• Signs of sepsis (confusion, hypotension)
• Severe, localized pain inconsistent with typical fibromyalgia pattern
• New neurological symptoms

By following this structured approach, clinicians can effectively manage fibromyalgia flares with fever while ensuring that any concurrent infections are appropriately identified and treated.