Fibromyalgia

1. Fibromyalgia Erin Fouch October 31, 2005

2. Diagnostic Criteria • American College of Rheumatology Diagnostic Criteria (1990)1 • Pain in all 4 quadrants of body and axial skeleton. • Tenderness in 11/18 previously defined “tender points.” • Fulfillment of both criteria results in approximately 80% sensitivity and specificity for diagnosis.

3. Tender Points • Appropriate pressure is 4 kg/cm– approximately enough to turn the examiner’s nailbed white. http://fibromyalgia.ncf.ca2

4. Case Presentation A 35-year-old woman presents to your office complaining of diffuse “joint pain” for the past several months. On further questioning, she states that the pain is all over her body, in her muscles and joints. It is there throughout the day, and worsened by exercise. She gets minimal relief with acetaminophen.

5. Epidemiology • Most common cause of musculoskeletal pain in women aged 20-55 • Prevalence ~3.5% in women, ~0.5% in men • Some familial aggregation • 50% of cases preceded by a stressor (injury, viral illness– e.g. Lyme disease) • Patients with FM have a 50% lifetime hx of depression, although only 25% meet criteria at the time of diagnosis

6. Case Cont’d ROS: Positive for daytime fatigue, constipation, and occasional palpitations. PMH: None. Meds: Acetaminophen prn FH: Mother has RA, sister has hypothyroidism.

7. Case Cont’d Physical Exam T 36.5; BP 125/78; P 65 Genl: WNWD, thin woman, NAD, slightly flat affect Neck: No thyromegaly, no LAD. CV: RRR, no murmur Lungs: Clear Abd: Soft, slightly tender throughout, ND MSK: No joint swelling nor erythema. Normal range of motion in all joints. 8/18 tender points positive Skin: No rashes.

8. Case Cont’d • What is your differential diagnosis? • What further work-up does she need?

9. Differential Diagnosis • Polyarticular arthritis • Rheumatoid arthritis • SLE • Polymyalgia rheumatica • Endocrine disorders • Hypothyroidism • Hyperparathyroidism (hypercalcemia) • Myopathies • Polymyositis • Rhabdomyolysis

10. Differential Diagnosis • Neuropathies • Depression • Chronic fatigue syndrome • Myofascial pain syndrome • Anemia

11. Case Cont’d What further work-up does our patient need?

12. Diagnostic Evaluation • Careful history and physical • This is the most important component and often leads to the diagnosis • Labs to evaluate for: • Causes of fatigue (CBC, TSH) • Causes of myalgias (CK, ? Chemistry panel) • Evidence of inflammation (ESR)

13. Diagnostic Evaluation • Generally NOT recommended • ANA, Rheumatoid factor

14. Diagnostic EvaluationDifferentiating FM from other disorders

15. Case Cont’d Your patient’s CBC, Chem 7, TSH, and ESR are normal. She returns to clinic for a follow-up visit to review her labs. You are about to begin explaining her diagnosis of fibromyalgia when she tells you that she forgot to mention last time that she has joint swelling in her hands, wrists, knees, and ankles, as well as mild shortness of breath with exertion.

16. Case Cont’d Concerned, you repeat an exam. She states that the joint swelling is present now, but you see no synovitis. Lungs are clear, but you remain worried that you have made the wrong diagnosis.

17. Rheumatoid arthritis (12%) SLE Hepatitis C Myofascial pain syndrome TMJ IBS Osteoarthritis (7%) Depression Migraine headaches OSA Restless legs Overlapping Syndromes and SymptomsCommon Comorbidities:

18. Common symptoms Fatigue Subjective joint/muscle swelling Difficulty sleeping Night sweats Dyspnea Palpitations Pelvic pain Dysmenorrhea Non-cardiac chest pain Diarrhea/constipation (IBS) Overlapping Syndromes and Symptoms

19. Case Cont’d In young, otherwise healthy patients with a variety of diffuse complaints and a relatively straightforward diagnosis of fibromyalgia, it is reasonable to monitor most symptoms rather than investigate exhaustively.

20. Case Cont’d You inform your patient that you believe she has fibromyalgia. She becomes tearful and says that she has read about this disease on the internet and it is clearly not a real illness. Furthermore, she has read that fibromyalgia is strongly associated with depression, and she adamantly states that she is not depressed. She would love to get back to the activities she used to enjoy, if only she did not have so much pain. She demands a referral to a rheumatologist for further evaluation.

21. Depression and Fibromyalgia • Of patients with fibromyalgia, 50% have had or will have depression at some time in their lives • 25% of FM patients will meet criteria for depression at the time of diagnosis • This means that 75% of patients will NOT be depressed when diagnosed with fibromyalgia • Disturbed sleep and fatigue could be symptoms of either illness • Some antidepressants have been used to treat fibromyalgia

22. Case Cont’d Your patient accepts that you are not diagnosing her with depression, and asks you what treatments are available. Her friend is on oxycodone for her chronic pain, and your patient would like a prescription for this as it is the only thing that has helped her friend.

23. Treatment of Fibromyalgia Patient Education • Patients generally have fewer symptoms if they are told their diagnosis • Group sessions (6-17 sessions), lectures, written materials seem to improve quality-of-life, pain, sleep, energy levels3; improvements lasted 3-12 months • One 1.5-day educational session improved energy, stiffness, pain severity, and depression4

24. Treatment of Fibromyalgia Aerobic Exercise • A 2002 Cochrane review5 found that aerobic exercise is an effective treatment for fibromyalgia. Patients had improved pain thresholds, decreased pain, and improved aerobic exercise capacity. • Strengthening exercises appear to provide some improvement. • Both aerobic exercise and strengthening exercises appear to be more effective than stretching.

25. Treatment of Fibromyalgia Aerobic Exercise • Patients should be counseled to start slowly– they will often feel worse if they embark on a strenuous exercise regimen quickly. • Swimming and water sports appear to be well-tolerated.

26. Treatment of Fibromyalgia Cognitive-Behavioral Therapy • A review by Goldenberg et al concluded that patients receiving CBT had decreased pain and improved function over 6-30 month follow-up.3

27. Treatment of Fibromyalgia Medications-- SSRIs • Variable results with fluoxetine, but it appears to improve pain when providers are allowed to escalate the dose to up to 80 mg/day6 • No improvement found with a fixed dose of fluoxetine (20 mg/day)7 • Pain appears to improve regardless of improvement in mood

28. Treatment of Fibromyalgia Medications– Tricyclic antidepressants • Amitriptyline 25-50 mg qhs effective in multiple RCTs • Cyclobenzaprine (Flexeril) 10-40 mg qhs also effective in multiple RCTs • Patients should be allowed to determine the maximum effective dose • Side effects limit use and dose escalation

29. Treatment of Fibromyalgia Medications-- Other • Pregabalin (a new anticonvulsant) was found to decrease severity of pain in one RCT8 • Combination of carisoprodol (Soma), Tylenol, and caffeine improved sleep, pain, and pain threshold more than placebo9 • Tramadol 75 mg q 6 hrs appears to improve pain; effect may be greater with Acetaminophen 650 mg q 6 hrs10

30. Amitriptyline Cyclobenzaprine Tramadol Fluoxetine Venlafaxine Duloxetine Pregabalin Treatment of FibromyalgiaMedications with “strong” or “moderate” evidence for efficacy3

31. Ineffective Medications Corticosteroids Opioids NSAIDs Benzodiazepines Guaifenesin Levothyroxine Cacitonin Melatonin Magnesium Treatment of Fibromyalgia

32. Case Continued You work out a treatment plan with your patient. She agrees to exercise daily, and try Amitriptyline at night. She asks you if she should take time off work or expect to be debilitated from her illness.

33. Natural history of fibromyalgia • Patients should be reassured that fibromyalgia is not life-threatening. • Most patients have waxing and waning symptoms throughout life, but generally remain very functional. • Most patients report that they are able to work full-time. • Patients should be encouraged to take an active role in disease management.

34. Fibromyalgia: take-home points • Defined as diffuse pain and 11/18 positive tender points, though some patients will not strictly meet criteria • Check CBC, ESR, TSH, CK depending on symptoms • Most effective treatments: Patient education; aerobic exercise; CBT; TCAs • Most patients will continue to have some pain but will function relatively normally

35. References • Wolfe F, Smythe HA, Yunus MB, Bennett RM, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990; 33:160 • Fibromyalgia Information website: http://fibromyalgia.ncf.ca • Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004; 292 (19); 2388 • Pfeiffer A, Thompson JM, Nelson A, et al. Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study. Am J Phys Med Rehabil. 2003; 82: 186. • Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. Cochrane Review Datatbase Systematic Review. 2003; 3. • Arnold LM, Hess EV, Hudson JI, Berno SE, Keck PEA. Randomized, placebo-controlled, double-blind study of fluoxetine in the treatment of women with fibromyalgia. Am J Med. 2002; 112: 191. • Wolfe F, Cathey MA, Hawley DJA. Double-blind placebo controlled trial of fluoxetine in fibromyalgia. Scand J Rheumatol. 1994; 23: 255. • Crofford L, Russell IJ, Mease P, et al. Pregabalin improves pain associated with fibromyalgia syndrome in a multicenter, randomized, placebo-controlled monotherapy trial. Arthritis Rheum. 2002; 46: S613. • Vaeroy H, Abrahamsen A, Forre O, Kass E. Treatment of fibromyalgia (fibrositis syndrome): a parallel double blind trial with carisoprodol, paracetamol and caffeine versus placebo. Clin Rheumatol. 1989; 8:245. • Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. Am J Med. 2003; 114:537. • Goldenberg DL. Clinical manifestations and diagnosis of fibromyalgia in adults. UpToDate 2005. • Goldenberg DL. Differential diagnosis of fibromyalgia. UpToDate . 2004. • Goldenberg DL. Treatment of fibromyalgia in adults. UpToDate. 2005. • Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with cyclobenzaprine: a meta-analysis. Arthritis Rheum. 2004: 51:9. • Klippel JH. Primer on the Rheumatic Diseases, Edition 12.