The Correct Answer is C!

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A 42 year-old white woman who is an accountant presents to the doctor’s office with a 4-year history of worsening myalgias and arthralgias. She reports debilitating fatigue and difficulty concentrating. She sleeps poorly and wakes up feeling tired. She was recently divorced and has a stressful job. Review of systems is negative for rash, pleurisy, oral ulcers or joint swelling. Symptoms have not improved with over-the-counter anti-inflammatory medications. Her past medical history includes interstitial cystitis, irritable bowel syndrome and tension headaches. She takes multiple natural supplements. Physical examination shows multiple soft tissue tender points without joint synovitis. Laboratory studies including complete blood count, markers of inflammation, chemistries, muscle enzymes, Vitamin D, thyroid function tests, rheumatoid factor and anti-CCP antibody are all unremarkable. The anti-nuclear antibody (ANA) is borderline at 1.2 (normal < 1.0), the double stranded DNA antibody is negative and antibodies to extractable nuclear antigens (ENA) are not present. Overnight oximetry study is normal. 

Which of the following therapeutic interventions would be most appropriate to order?

  1. Prednisone
  2. Oxycodone
  3. Milnacipran
  4. Hydroxycholoquine


Milnacipran is the most appropriate therapeutic intervention because it is effective for treatment of fibromyalgia. The patient’s clinical presentation, physical examination and laboratory studies are consistent with a diagnosis of fibromyalgia. Milnacipran is a selective serotonin and norepinephrine reuptake inhibitor. In clinical trials, it was substantially better than placebo for reducing pain and other symptoms of fibromyalgia. The standard dose of milnacipran for fibromyalgia is 50 mg by mouth twice daily. However, it is usually started at 12.5 mg daily and gradually increased over about a week to the target dose of 50 mg twice daily. Patients with fibromyalgia should not be treated with narcotic medications due to risk of dependency. There is no evidence that tissue inflammation is present in patients with fibromyalgia, and therefore corticosteroid therapy is ineffective. Although the patient has a borderline anti-nuclear antibody (ANA), she has no clinical features of systemic lupus and the specific serologies are negative; therefore hydroxychloroquine is not indicated.

1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.