What is the best approach to manage symptoms of tachycardia, pain, fatigue, sensory issues, and decreased sleep in a patient with hypermobile Ehlers-Danlos Syndrome (hEDS), fibromyalgia, and musculoskeletal issues, who recently stopped consuming 2-3 glasses of red wine nightly?

Management of Post-Alcohol Cessation Symptoms in hEDS and Fibromyalgia

The patient's symptoms of tachycardia, pain, fatigue, sensory issues, and decreased sleep following alcohol cessation should be managed through a structured multidisciplinary approach prioritizing cardiovascular surveillance for POTS, low-resistance physical therapy for musculoskeletal symptoms, and pregabalin for fibromyalgia pain, while avoiding opioids and recognizing that alcohol withdrawal may be unmasking underlying autonomic dysfunction. 1, 2

Immediate Cardiovascular Assessment

Screen for POTS immediately by measuring postural vital signs with an active stand test: document heart rate increase ≥30 beats/min within 10 minutes of standing without orthostatic hypotension, as autonomic dysfunction affects up to 37.5% of hEDS patients and may have been masked by alcohol's sedative effects. 1, 3

• The tachycardia and sensory issues may represent POTS rather than simple alcohol withdrawal, given the high prevalence of autonomic dysfunction in hEDS. 1, 3
• If postural vital signs confirm POTS, refer for tilt table testing and expanded autonomic function assessment. 1
• Cardiovascular symptoms in hEDS often require focus on functional maintenance rather than cure. 3

Fibromyalgia Pain Management

Initiate pregabalin for fibromyalgia pain management, starting at 75 mg twice daily (150 mg/day), with potential titration to 150 mg twice daily (300 mg/day) within 1 week based on efficacy and tolerability. 2

• Pregabalin may be further increased to 225 mg twice daily (450 mg/day) if insufficient benefit at 300 mg/day, though doses above 450 mg/day are not recommended due to dose-dependent adverse reactions without additional benefit. 2
• Pregabalin demonstrated significant pain reduction in fibromyalgia patients, with 68.1% showing improvement at 300 mg/day and 77.8% at 450 mg/day versus 47.6% with placebo. 2
• Some patients experience pain decrease as early as Week 1, which persists throughout treatment. 2

Musculoskeletal Pain and Physical Rehabilitation

Initiate low-resistance exercise and physical therapy as the cornerstone of treatment for musculoskeletal pain, focusing on increasing muscle tone through therapeutic exercise and motor function training to improve joint stability. 1, 4

• Physical therapy should emphasize strengthening periarticular muscles rather than muscle relaxation, as joint instability drives pain in hEDS. 1, 4
• Swimming and low-impact weight-bearing exercise are preferred activities that improve muscle tone without excessive joint stress. 1, 4
• Myofascial release techniques combined with low-resistance exercise are specifically recommended during acute flares. 4

Sleep Disturbance Management

Address sleep disturbances systematically, as they are one of five key determinants of fatigue in EDS and may be exacerbated by alcohol withdrawal. 5

• Screen for sleep disorders that commonly coexist with hEDS and fibromyalgia, as sleep disturbances directly contribute to fatigue severity. 5
• Pregabalin may provide dual benefit for both pain and sleep quality in fibromyalgia patients. 2
• Avoid centrally-acting muscle relaxants like baclofen or methocarbamol, as they can worsen sedation and gastrointestinal symptoms in hEDS patients. 4

Fatigue Management Strategy

Screen for common comorbidities contributing to fatigue: POTS (already addressed above), celiac disease, and vitamin D deficiency. 1

• Test celiac disease serological markers earlier in hEDS patients with any GI symptoms, as risk is elevated. 1
• Check vitamin D levels and supplement if deficient, as this is common and contributes to musculoskeletal symptoms. 1, 4
• The five key determinants of fatigue in EDS are sleep disturbances, concentration problems, social functioning, self-efficacy concerning fatigue, and pain severity—all should be addressed. 5

Gastrointestinal Symptom Surveillance

Inquire specifically about gastrointestinal symptoms, as up to 98% of hEDS patients develop GI manifestations including reflux, abdominal pain, constipation, and functional bowel symptoms. 6, 1

• Alcohol cessation may unmask previously suppressed GI symptoms common in hEDS. 6
• The association of hEDS with gut symptoms encompasses visceral hypersensitivity rather than true dysmotility in most cases. 6
• Exercise caution when considering escalating invasiveness of nutrition support in pain-predominant presentations. 6

Psychological Support and Behavioral Interventions

Provide or refer for psychological support and brain-gut behavioral therapies, as anxiety and psychological distress are common in hEDS and significantly impact quality of life. 1, 4

• Psychological distress is common in hEDS patients, and an MDT approach including clinical psychology expertise is ideal. 6
• The patient's previous use of alcohol to "wind down" suggests underlying anxiety or stress that requires formal assessment and treatment. 1
• More than three-quarters of EDS patients suffer from severe fatigue with higher levels of psychological distress. 5

Critical Medications to Avoid

Never prescribe opioids for chronic pain management in hEDS patients, particularly when GI manifestations are present. 1, 4

• Opioids can contribute to dysmotility and worsen outcomes in hEDS patients. 6, 1
• The American Academy of Pain Medicine specifically recommends avoiding opioids in hEDS patients with chronic pain. 1, 4

Monitoring and Follow-Up

• Perform echocardiography to evaluate aortic root diameter, as dilation occurs in 25-33% of hEDS cases. 1
• Repeat echocardiography every 2-3 years if trivial mitral valve prolapse without regurgitation and normal aortic root size. 1
• Monitor for treatment response to pregabalin within 1-2 weeks, with dose adjustments based on efficacy and tolerability. 2

Common Pitfalls to Avoid

• Do not attribute all symptoms to alcohol withdrawal—many may represent unmasked hEDS/fibromyalgia manifestations, particularly POTS. 1, 3
• Avoid invasive diagnostic procedures unnecessarily, as tissue fragility increases complication risk in hEDS. 1
• Do not use muscle relaxants as substitute for physical therapy, as this undermines the primary therapeutic goal of strengthening periarticular muscles. 4
• Recognize that conventional medical therapies produce limited benefits in fibromyalgia, requiring multimodal approach. 7, 8