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1 대한내과학회지 : 제 84 권제 5 호 종설 (Review) 섬유근통증후군의진단과치료 전남대학교의과대학내과학교실 이신석 Diagnosis and Treatment of Fibromyalgia Syndrome Shin-Seok Lee Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea Fibromyalgia syndrome (FMS) is characterized by chronic widespread pain and various accompanying symptoms including fatigue, sleep disturbances, and cognitive dysfunction. While the etiology of fibromyalgia is unclear, accumulating data suggest that disordered central pain processing likely plays a role in the pathogenesis of symptoms. Although the 1990 American College of Rheumatology (ACR) classification criteria for FMS were originally developed for research purposes and were not intended for clinical diagnosis, the criteria have become the de facto diagnostic criteria in clinical settings. Recently, an improved clinical case definition for FMS was proposed by ACR in 2010 to overcome several limitations of 1990 ACR criteria. Further studies are needed to assess the acceptance, reliability, and validity of the new criteria in epidemiologic and clinical studies. Many randomized controlled trials and meta-analyses confirm the therapeutic efficacy of pregabalin, duloxetine, and milnacipran, in the treatment of FMS. In view of the currently available evidence, a combination of pregabalin, duloxetine, or milnacipran as pharmacological interventions and aerobic exercise or CBT as non-pharmacological interventions seems most promising. (Korean J Med 2013;84: ) Keywords: Diagnosis; Treatment; Fibromyalgia syndrome 서론만성통증은침범부위에따라만성국소통증 (chronic regional pain) 과만성전신통증 (chronic widespread pain) 으로분류되는데만성전신통증은신체의좌, 우측부위와허리를기준으로상하부위의 3개월이상지속되는통증을말한다. 미국과영국의역학조사에의하면전체인구의 20-25% 가만성국소통 증을가지고있고 10-11% 는만성전신통증을가지고있다고한다. 최근국내의조사에서도비슷한빈도의만성통증환자가있는것으로보고되고있다 [1]. 1990년미국류마티스학회에서는만성전신통증이있으면서특정부위에압통점이있는경우를섬유근통증후군으로분류하였는데이전에섬유조직염, 비관절성류마티즘, 정신성류마티즘등으로불리던질환들이섬유근통증후군혹은섬유근통 ( 이하섬유근통 ) Correspondence to Shin-Seok Lee, M.D., Ph.D. Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju , Korea Tel: , Fax: , shinseok@chonnam.ac.kr Copyright c 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - Shin-Seok Lee. Diagnosis and treatment of fibromyalgia syndrome - 으로통일되게된것이다 [2]. 압통점은 4 kg의무게로신체의일부를손가락으로눌렀을때통증을호소하는부위를말하고 1990년미국류마티스학회의섬유근통분류에서는 18개의가능한압통점을제시하였고이중 11부위이상에서통증을호소하게되면섬유근통이라고하였다. 서구에서는전체인구의 1-2% 가섬유근통에해당된다고보고되어있고국내의조사에서도서구와비슷한빈도의섬유근통환자가있는것으로보고된바있다 [3]. 영국의경우섬유근통은전체입원환자의 5% 을차지하고내과외래환자의 6%, 류마티스외래환자의 20% 를차지하는중요한질환으로되어있다 [4]. 섬유근통은불안, 우울, 기억력감퇴와같은정신증상들이자주동반되고과민성대장염과같은정신신체증상들이동반될수있기때문에섬유근통을정신질환으로보는견해도있다. 일부우울증이있는환자에서섬유근통이발생할수있지만대부분은정신적으로건강한환자에서만성전신통증에동반되어불안, 우울과같은정신증상이발생한다는사실과섬유근통환자에서정신증상이동반된환자보다는그렇지않은환자들이더많다는사실을고려해볼때섬유근통을정신질환과구별되는하나의독립된질환으로보고섬유근통이신체형장애의증상과서로중복될수도있다고 보는것이옳다 [5]. 섬유근통은다른류마티스질환들처럼유전적인소인이있는사람들이특정환경인자에노출되었을때발병한다 [6]. 여러가지환경요인들가운데섬유근통을유발하는것으로알려진것들로는인플루엔자와같은바이러스감염, 육체적인외상, C형간염, 정신적인스트레스, 갑상샘저하증과같은내분비질환이있다. 또한류마티스관절염, 전신홍반루푸스와같은류마티스질환의 25% 에서섬유근통이동반된다. 섬유근통의발병기전으로는근육자체에문제가있다는 골격근가설, 느린눈운동수면 (nonrapid eye movement, NREM 수면 ) 중나타나는비정상적인알파파에의해섬유근통의증상이발생한다는 " 수면장애가설 " 등여러가지이론이있지만중추신경계에서통증을조절하는데문제가있어섬유근통이발병한다는가설이가장많은인정을받고있다 [7]. 섬유근통의진단섬유근통은비교적흔한질환임에도불구하고진단에이르는데평균 5년이소요되고전제환자의 25% 만이진단되고있어진단자체만으로도건강상태에긍정적인효과를가져올수있다 [8]. 적절한진단을통해불필요한혈액검사 Table 1. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia a 1. History of chronic widespread pain. Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain. 2. Pain in 11 of 18 tender point sites on digital palpation. Definition. Pain, on digital palpation, must be present in at least 11 of the following 18 sites: Occiput: Bilateral, at the suboccipital muscle insertions. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. Trapezius: bilateral, at the midpoint of the upper border. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border. Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. Greater trochanter: bilateral, posterior to the trochanteric prominence. Knee: bilateral, at the medial fat pad proximal to the joint line. Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender" is not to be considered "painful." a For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia. Adapted from reference [2]

3 - 대한내과학회지 : 제 84 권제 5 호통권제 633 호 와방사선촬영을줄일수있고불필요한약물복용도줄일수있으며협진의빈도도줄일수있기때문에적절한진단기준을사용하여조기에진단을하는것이중요하다고할수있다 [9]. 국내에서진행된다기관연구를보더라도진단받기 3개월전후를비교해보았을때진단후삶의질이의미있게개선되었고의료비용의지출역시의미있게감소하여조기진단의중요성은아무리강조해도지나치지않는다고할수있다 [10]. 섬유근통의진단은 1990년미국류마티스학회에서제시 한분류기준 (Table 1) 을진단근거로사용해왔다 [2]. 1990년분류기준에의하면섬유근통은 3개월이상지속되는만성전신통증이있으면서 18군데의압통점가운데 11군데이상에서압통을호소할때섬유근통으로진단할수있다. 1990년분류기준은섬유근통에관한하나의통일된분류기준을제안함으로써섬유근통에대한연구를용이하게했다는점에서긍정적인의미를부여할수있지만진단기준이아니라는점, 만성전신통증이있는환자가운데극단적으로심한상태의환자만을섬유근통으로분류하였다는점, 그리고나 Table American College of Rheumatology diagnostic criteria Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1. Widespread pain index (WPI) 7 and symptom severity (SS) scale score 5 or WPI 3-6 and SS scale score Symptoms have been present at a similar level for at least 3 months. 3. The patient does not have a disorder that would otherwise explain the pain. Ascertainment 1. WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. Shoulder girdle, left; Hip (buttock, trochanter), left; Jaw, left; Upper back Shoulder girdle, right; Hip (buttock, trochanter), right; Jaw, right; Lower back Upper arm, left; Upper leg, left; Chest; Neck Upper arm, right; Upper leg, right; Abdomen Lower arm, left; Lower leg, left Lower arm, right; Lower leg, right 2. SS scale score: Fatigue Waking unrefreshed Cognitive symptoms For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale: 0 = no problem 1 = slight or mild problems, generally mild or intermittent 2 = moderate, considerable problems, often present and/or at a moderate level 3 = severe: pervasive, continuous, life-disturbing problems Considering somatic symptoms in general, indicate whether the patient has: a 0 = no symptoms 1 = few symptoms 2 = a moderate number of symptoms 3 = a great deal of symptoms The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12. a Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms. Adapted from reference [13]

4 - 이신석. 섬유근통의진단과치료 - 머지만성전신통증환자에대해서는어떻게접근을해야하는지구체적인지침이없다는점에서보완될필요성이있었다. 특히, 압통점검사와관련해서는많은논란이있어왔다. 섬유근통의병태생리가중추신경계에서통증을조절하는데문제가있어섬유근통이발생한다는사실이널리받아들여지고있는데압통점검사가자칫근육자체에문제가있어섬유근통이발생하는것처럼비쳐질수있다는점에서압통점검사의필요성이의문시되어왔다. 또한현실적인문제점으로압통점검사가일차진료의사들사이에서거의시행되지않고심지어는많은일차진료의사들이압통점검사하는방법을모른다는것이다 [11]. 한편 1990년분류기준은섬유근통의통증에초점이맞춰져있기때문에섬유근통환자에서흔히동반되는수면장애, 피로, 신체증상과같은섬유근통의주된증상에관한내용이빠져있어이들증상이진단기준에포함될필요성이제기되어왔다 [12]. 따라서이러한문제점들을개선시키기위해 2010년미국류마티스학회에서는섬유근통의새로운진단기준 (Table 2) 을발표하게되었다 [13]. 새로운진단기준은압통점이진단기준에서빠지게되어섬유근통을좀더수월하게진단할수있게되었고다양한임상증상들을진단기준에포함시키게됨에따라상당수의만성전신통증환자들을섬유근통으로진단할수있게되었다는점에서의미가있다고본다. 미국류마티스학회의 2010년기준은표 2에서보는것처럼두가지내용으로구성되어있는데첫째는전신통증지수 (widespread pain index, WPI) 이고둘째는증상중증도척도 (symptom severity scale) 이다. WPI 를평가하는방법은환자와직접면담을하면서한부위한부위씩표시하는방법이가장권장되고여의치않는경우에는환자에게체크리스트를주거나마네킹그림을주어서환자스스로표시하도록하는것도가능하다 [14]. 증상중증도척도는피로, 잠에서깨어날때의기분, 기억력이나집중력정도, 신체증상정도를각각 3점척도로평가하도록되어있다. 증상중등도는환자스스로설문지를보고답하는것이아니라검사자가환자와충분하게면담을한다음평가하도록되어있다. WPI 와증상중증도의최대점수는각각 19점과 12점이고섬유근통으로진단하기위해서는 WPI가 7점이상이면서증상중증도가 5 점이상이거나 WPI가 3-6점사이인경우에는증상중등도가 9점이상이어야한다. 2010년기준이발표되면서이새로운기준에대해여러 가지논란이있는것도사실이다. 먼저압통점검사가진단기준에서배제되었는데일부에서는압통점검사가섬유근통환자에서감소되어있는통증역치를객관적으로평가할수있는유일한방법이기때문에압통점검사가필요하다는의견도있다 [15]. 한편, 2010년기준의경우압통점검사없이면담에의해진단이이루어지기때문에진단에소요되는시간이훨씬더길어지게되었다. 1990년분류기준에의해압통점검사를하게되면 1분이내에진단이가능하지만 2010년기준은최소 5분이상이소요되고제대로인터뷰를하자면 10분이상이소요되기때문에 2010년기준이널리보급되는데장애가될수도있다. 둘째, 전신홍반루푸스, 류마티스관절염과같은다른류마티스질환과의감별이어렵고특히, 근막통증증후군과의감별이어렵다는보고들이있다 [16]. 이런논란이지속되고있는것은 1990년기준과달리 2010년기준은정상인을대상으로진단기준이개발되었기때문에당연한논란으로볼수있고 1990년분류기준의경우분류기준이발표된후여러연구들을통해타당도가검증된반면 [17,18] 2010년진단기준은아직타당도가검증되지않은탓이크다고본다. 향후 2010년기준이좀더널리보급되려면류마티스질환을포함하여다양한만성질환들을대상으로타당도를검증하는일이시급하다고하겠다. 셋째, 2010년기준은환자의증상에초점을맞춘것이기때문에질환의특성 (trait) 을충분히반영했다고보기어렵다. 따라서이것은앞으로도계속해서문제점으로지적될가능성이높다. 넷째, 2010년진단기준은 WPI와증상중등도가일정점수이상진단기준을만족시키면서통증을설명할수있는다른질환이없어야섬유근통으로진단할수있다고되어있다. 예를들어전신홍반루푸스, 류마티스관절염, 골관절염에의한이차성섬유근통은 1990년기준에의하면섬유근통으로진단하는데전혀문제가없지만 2010년기준에의하면동반질환이있는경우진단을할수없는경우가생길수있다 [19]. 이차성섬유근통은임상증상, 치료, 약제에대한반응에있어원발성섬유근통과차이가없기때문에근래에는이둘을서로구분하지않은것이일반적이다. 따라서동반질환에관계없이섬유근통의증상이있으면섬유근통으로진단할수있도록하는것이바람직하지동반질환이있는경우진단을어렵게하는것은결코바람직하지않다고본다. 다섯째, 2010년진단기준은정상인에서 9.1% 의유병률을나타내는것으로보고되어있기때문에 1990년분

5 - The Korean Journal of Medicine: Vol. 84, No. 5, 류기준을적용했을때보다적어도 4배이상유병률이증가한다. 따라서어떤진단기준을적용했느냐에따라각기다른환자군이정의될가능성이높고여기에따라임상증상, 치료, 예후에대해서도서로다른결과가나올가능성이농후하다 [20]. 향후 2010년진단기준이정착되려면앞서언급된많은문제점들을해결하기위한별도의임상연구들이추가로진행될필요가있다. 2010년진단기준과관련하여한가지언급될필요가있는것은원개발자가강조한대로이기준은 1990년분류기준을대체하기위해개발된것이아니라일차진료의사들이손쉽게섬유근통을진단할수있도록도움을주기위해개발되었다는것이다. 이러한개발자의개발의도를안다면 2010년기준의활용범위와용도를명확하게정의할수있을것으로판단된다. 국내에서는섬유근통치료약제들의보험급여가이루어지기위해서는 1990년분류기준을만족해야하는데 2011년 9월부터는 2010년진단기준으로보험급여가이루어지고있다. 섬유근통의치료섬유근통은아직까지발병기전과병태생리가완전히밝혀지지않아치료는증상을완화시키는것이주가된다. 일차적으로섬유근통에대한이해가중요한데섬유근통은류마티스관절염과달리염증성질환이아니기때문에불구가되거나관절이변형되지않는다는사실을알필요가있고인터넷이나소문에근거한잘못된치료에매달리지않도록주의를해야한다. 또한정신적인요인이섬유근통의발생과관련이있을수있고만성적인통증으로인해우울과불안이동반될수있지만정신질환은아니라는사실을분명히해두어야한다. 최근에는섬유근통의증상조절에효과가있는약제들이개발됨에따라많은임상연구들이진행되고있다. 특히, 2007년 6월에 pregabalin이미국 FDA로부터섬유근통치료제로처음승인을받았고 2008년 6월에는 duloxetine이 2009 년 1월에는 milnacipran이미국 FDA로부터승인을받았으며조만간몇몇약제들이추가로승인을받을예정이어서섬유근통의약물치료에대한관심이그어느때보다높다고할수있다. 과거뚜렷한치료약제가없었을때에는약물치료보다는비약물치료가우선시되었으나최근효과적인치료약제들의등장으로비약물치료보다는약물치료가더중요 시되고있다. 따라서여기에서는섬유근통의약물치료를중심으로치료에대한전반적인내용을기술하고자한다. 약물치료섬유근통환자에서는세로토닌과세로토닌의전구물질인트립토판의혈중농도가감소되어있고뇌척수액에서는세로토닌의대사물질인 5-hydroxyindoleacetic acid, 노르에피네프린, 그리고노르에피네프린의대사물질인 3-methoxy-4- hydroxyphenethylene이감소되어있어중추신경계와척수에서통증을억제하는작용을하는신경전달물질인세로토닌과노르에피네프린이감소되어있다는것을알수있다 [21]. 반면뇌척수액에서 substance P와같은통증전달물질들이증가되어있는데이는섬유근통환자에서중추신경계의통증조절에이상이있음을보여주는증거라고할수있다. 약물치료도이러한발병기전에맞춰감소되어있는세로토닌과노르에피네프린의농도를올리는약제와증가되어통증전달물질을억제시키는약제를사용해서치료를한다. 세로토닌과노르에피네프린의농도를증가시키는약제들은일반적으로항우울제로알려져있고이부류에속하는약제들로는삼환계약물 (tricyclic agents), 선택적세로토닌재흡수억제제 (selective serotonin reuptake inhibitor, SSRI), 세로토닌노르에피네프린재흡수억제제 (serotonin-norepinephrine reuptake inhibitor, dual reuptake inhibitor, SNRI) 가있다. SSRI로는 fluoxetine, citalopram, paroxetine 등이있고이들약제가운데가장효과적인것은 fluoxetine이다. Citalopram 의경우지금까지발표된두개의임상시험에서의미있는통증개선효과를보이지못했고 [22,23] paroxetine도 2007년에발표된서방형 paroxetine과위약을비교한임상시험에서의미있는통증개선효과를보이지못했다 [24]. Fluoxetine의경우 2002년에발표된 12주무작위대조시험에서통증과섬유근통영향평가등다양한임상결과들을개선시켜 fluoxetine 이섬유근통의치료에효과적이다는것을증명하였고 [25] fluoxetine과 amitriptyline 병합요법에대한임상시험에서는단독치료보다병합요법을시행한경우가더효과적이었다 [26]. 효과면에서 SSRI 제제들사이에차이가나는이유로는세로토닌이신경시냅스에서어떻게작용을하는지와관련이있다. 세로토닌은시냅스후신경말단에서는통증을억제시키지만시냅스전신경말단에서는오히려통증을유발시키기때문에 SSRI 가운데 norepinephrine 농도에전혀영향을

6 - Shin-Seok Lee. Diagnosis and treatment of fibromyalgia syndrome - 미치지않는 citalopram 보다는어느정도 norepinephrine 농도를증가시켜주는 fluoxetine이더효과적이다고할수있다. SSIR는저녁에복용을하는경우불면증을일으킬수있기때문에가급적오전에복용을해야한다. SSRI에효과가충분치않는경우에는 duloxetine, milnacipran, venlafaxine과같은 SNRI 로교체를해볼필요가있다. SNRI 가운데 duloxetine은동물실험에서 amitriptyline, paroxetine, venlafaxine보다통증을개선시키는데더효과적이라는보고가있고 2004년에발표된다기관무작위대조시험에서는대조군에비해섬유근통의증상을개선시키는데유의한차이를보였다 [27]. Duloxetine 임상시험에서인상적인것은 duloxetine의효과가항우울작용을통한간접적인효과가아니라척수또는뇌의통증전달로에직접작용하여통증을조절할것이라는사실을보여주었고삼환계항우울제와달리압통점의숫자를감소시킨다는것이다. 이후 6개월다기관무작위대조시험결과가발표되었는데여기에서도 duloxetine 60 mg과 120 mg 투여군이대조군에비해통증과환자가판단한증상의개선정도에있어유의한차이를보였다 [28]. Duloxetine은 2008년 6월에 FDA로부터섬유근통에사용승인을받았고국내에서는 2009년 12월에승인을받았다. Duloxetine과비슷한 SNRI 로 milnacipran이있다. 125명의섬유근통환자를대상으로한임상 2상시험결과를보면 milnacipran을하루 1회혹은하루 2회투여한군에서대조군에비해통증을비롯한섬유근통의여러증상들이의미있게개선되었고한가지흥미로운점은기저질환으로우울증이동반된섬유근통환자보다우울증이동반되지않은환자에서통증이더많이개선되었다는것이다 [29]. 이것은 milnacipran의항우울작용에의해섬유근통의통증이개선된것이아니라 SNRI 가직접통증을개선시키는효과가있다는것을간접적으로보여주는결과라고할수있다. 최근에발표된 2개의 3상시험결과에서도 milnacipran 100 mg과 200 mg 투여군에서대조군에비해통증과섬유근통의다양한증상들이의미있게개선되었고 2상시험과마찬가지로우울증이동반된섬유근통환자보다우울증이동반되지않은환자에서더효과적이었다 [30,31]. Milnacipran은 2009년 1 월 14일에 FDA로부터섬유근통에사용승인을받았고국내에서는아직승인을받지못한상태이다. SSRI, SNRI 와달리 substance P와같은통증전달물질들을 억제시켜통증을개선시키는약제로 pregabalin이있다. Pregabalin은 α2-δ ligand 로칼슘전압작동통로 (voltage-gated calcium channel) 의보조단백인 α2-δ에결합하여신경말단에서칼슘의유입을차단한다. 신경말단에서칼슘의유입이차단되면 substance P와글루탐산염같은통증을유발하는신경전달물질의분비가억제되고이러한기전에의해진통, 항경련, 항불안작용을나타내는것으로알려져있다. 2005년에발표된다기관무작위대조시험에의하면, 하루 450 mg의 pregabalin이위약에비해통증을유의하게감소시킬뿐만아니라피로, 수면, 삶의질등을현저하게개선시키는것으로되어있다 [32]. SNRI 의임상시험에서처럼불안, 우울과같은정신적인측면은전혀개선되지않기때문에항우울작용에의해이차적으로섬유근통의증상이개선된다고보기는힘들것같다. 이후에각각 13주, 14주, 6개월다기관무작위대조시험결과가발표되었는데여기에서도 pregabalin 300 mg, 450 mg, 600 mg 투여군이대조군에비해통증, 섬유근통영향척도, 그리고환자가판단한증상의개선정도에있어의미있는호전을보였다 [33-35]. Pregabalin은 2007년 6월에 FDA로부터섬유근통에사용승인을받았고국내에서는 2007년 11월사용승인을받았으며보험급여는 2008년 11월부터되고있다. 앞서언급된약제들외에통증조절에효과가있는약제로 tramadol이있다. Tramadol은아편유사작용제 (opioid agonist) 이지만섬유근통에효과적인것은세로토닌과노르에피네프린의재흡수를억제하여진통효과를나타내기때문이다. Tramadol은섬유근통환자를대상으로한이중맹검교차시험과무작위대조시험에서통증을완화시키는효과가있는것으로보고되었고 [36] acetaminophen과 tramadol을병합한제제도다기관무작위대조시험에서위약에비해통증을비롯한섬유근통의여러증상들을의미있게개선시켰다 [37]. 따라서 tramadol은삼환계항우울제, SSRI, SNRI 등에조절되지않는통증이있는경우이들약제에추가해서사용해볼수있겠다. 섬유근통환자에서통증이외의다른증상들을개선시키기위해여러가지약제들을추가적으로사용해볼수있다. 심한피로를호소하는경우에는 modafinil과 methylphenidate 가도움이되고불면증에서는 zolpidem과 zopiclone이, 뻣뻣함에는 cyclobenzaprine과 tizanidine, 두근거림, 기립성저혈압과같은자율신경기능장애가있는경우에는저용량의베타

7 - 대한내과학회지 : 제 84 권제 5 호통권제 633 호 차단제가효과적이다. 글루코코르티코이드와아편성진통제의사용은결코바람직하지않다. 비약물치료섬유근통의비약물적치료로는여러가지가제안된바있지만효과가입증된것은운동요법과인지행동치료뿐이다. 섬유근통환자들을대상으로운동효과를평가한 28개의무작위대조군연구들을메타분석한결과를보면운동은통증과피로를감소시키고우울감과삶의질을개선시키며체력을의미있게향상시킨다 [38]. 하지만운동을중단하게되면통증감소효과는바로사라지기때문에운동을지속적으로하는것이중요하다. 운동은수중운동과육상운동모두효과적이고저강도또는중등도의강도로일주일에 2-3회최소 4주이상지속해야효과가있다. 운동이섬유근통의치료에도움이된다고해서환자의상태를고려하지않고처음부터운동을하도록하는것은오히려해가될수있기때문에환자의상태를고려하여통증이심한경우에는약물치료로증상을어느정도호전시킨후에시작할수있도록해야한다. 인지행동치료는조작조건화와관찰학습을통해행동을바꾸게하는기법으로정신질환외에다양한류마티스질환에서통증을조절할목적으로사용되고있다. 섬유근통환자들을대상으로인지행동치료의효과를메타분석한결과를보면인지행동치료는우울감과자기효능감을의미있게개선시킨다 [39]. 하지만통증, 피로, 수면, 삶의질과같은섬유근통의주된증상들은전혀개선시키지를못하기때문에주된치료방법으로활용하기에는한계가있다. 보완의학적인치료방법가운데메타분석이가능할정도로충분히연구가이루어진것들로는침술, 지압요법, 동종요법, 수치료, 마사지가있다 [40]. 이가운데지압요법은메타분석에서효과가없는것으로되어있고나머지침술, 동종요법, 수치료, 마사지는효과가미미하고잘짜인무작위대조군연구가많지않아적극적으로권장하기에는무리가있다고본다. 결론섬유근통은전신적인통증과특정부위의압통점을특징으로하는만성근골격계질환이다. 1990년미국류마티스학 회의분류기준이만들어지면서섬유근통에관한연구가본격화되었고유전적인소인이있는사람들이특정환경인자에노출되었을때발병한다는사실과중추신경계에서통증을조절하는데문제가있어섬유근통이발생한다는사실등이근래에새롭게밝혀졌다. 1990년분류기준은섬유근통에관한역학, 병태생리, 그리고치료에이르기까지섬유근통전반에걸쳐많은영향을끼쳤지만몇몇제한점들이있어이를개선하고자하는노력이최근까지지속되어왔다 년에발표된미국류마티스학회의진단기준은압통점검사없이설문만으로도진단할수있게되었고다양한임상증상들을진단기준에포함시키게됨에따라상당수의만성전신통증환자들을섬유근통으로진단할수있게되었다는점에서큰의미가있지만여전히해결해야할많은문제점들이있어이를해결하기위한별도의임상연구들을추가로진행할필요가있다. 섬유근통의치료에효과적인약물들로는 duloxetine, milnacipran, pregabalin이있고비약물적인치료방법으로는운동요법과인지행동치료가있다. 하지만어느한가지치료방법만가지고서는충분한치료효과를기대하기어렵기때문에적절한약물치료와함께운동요법을병행해나가는것이가장바람직한치료방법이라고할수있다. 중심단어 : 진단 ; 치료 ; 섬유근통증후군 REFERENCES 1. McBeth J, Jones K. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 2007;21: Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33: Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995;38: Doherty M, Jones A. ABC of rheumatology: fibromyalgia syndrome. BMJ 1995;310: Buskila D, Cohen H. Comorbidity of fibromyalgia and psychiatric disorders. Curr Pain Headache Rep 2007;11: Ablin JN, Cohen H, Buskila D. Mechanisms of Disease: genetics of fibromyalgia. Nat Clin Pract Rheumatol 2006;2: Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative

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untitled 대한류마티스학회지 Vol. 18, No. 3, September, 2011 http://dx.doi.org/10.4078/jrd.2011.18.3.153 REVIEW 섬유근통증후군의새로운진단기준과임상적의의 이신석 전남대학교의과대학류마티스내과학교실 Newer Diagnostic Criteria of Fibromyalgia and Its Clinical Implications