Fibromyalgia and Chronic fatigue syndrome

Andreea Harsanyi, Rheumatologist Hollywood Rheumatology

Summary

Case discussion

Fibromyalgia overview

How to treat chronic non-inflammatory pain

Chronic fatigue syndrome

Case 1

58 year old Caucasian lady widespread aches and pains for 7 years muscles and joints aggravated by activities (walking, gardening) “the more I do the worse it gets” no improvement with NSAID EMS- 30 minutes no joint swelling sicca symptoms sister with RA

Case 1

• Examination

• widespread tenderness (muscles and most joints)

• Heberden nodes, bilateral thumb squaring

• no objective synovitis

• Investigations • normal inflammatory markers • normal FBC, UE, LFT, TFT, Ca level • ANA 1:80 speckled • RF, ACCP negative

49 year old Indigenous lady

widespread aches and pains for one year

difficulties looking after her 4 grandchildren

good response to NSAID in the past

EMS ~up to 1 hour, especially hands

sicca symptoms, RP , but no other CTD symptoms

smoker

Case 2

Case 2

• Examination

• widespread tenderness (muscles and joints, esp MCP/PIPJ)

• no objective synovitis

• Investigations • normal inflammatory markers • normal FBC, UE, LFT, TFT, Ca level • ANA 1:160 speckled, ENA +ve (antiSm, RNP and SSA/SSB) • RF 14, ACCP negative

Differentiating...

• Fibromyalgia vs inflammatory arthritis/CTD

• FM + CTD or infl. arthritis

•30% of SLE

•20% of RA

•40% of Primary Sjogren syndrome

Figure 1 Prevalence rates for CWP and fibromyalgia by age and sex across the adult

lifespan

McBeth, J. & Mulvey, M. R. (2012) Fibromyalgia: mechanisms and potential impact of the ACR 2010 classification criteria

Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2011.216

History - FM associated

depression/anxiety ~ 30%

restless leg syndrome ~ 30%

irritable bowel syndrome

chronic fatigue

headaches

sicca symptoms

1.Pain 2.Fatigue 3.Non-restorative sleep 4.Mood disturbance 5.Impaired cognition

Clinical features of FM

Pain

long-standing widespread pain ‘all over their body’

often most their adult life (to some degree) - gradual onset

stressful event may precipitate symptoms/deterioration

muscles > joints

morning stiffness <15 min usually - not relieved by exercise

response to activity

worsens with increased exertion

often significantly worse the day after exertion

Figure 1 Pathways of pain processing implicated in chronic pain

and fibromyalgia

Schmidt-Wilcke, T. & Clauw, D. J. (2011) Fibromyalgia: from pathophysiology to therapy Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2011.98

•Pain •Fatigue

• ‘completely washed out’ • not improved by rest and sleep

•Non-restorative sleep • not refreshed in the morning • difficulties falling asleep • predictive of pain, fatigue and poor social functioning

•Mood disturbance • common, ~40% community vs 80% in secondary centers • anxiety > depression

•Impaired cognition • ‘brain fog’ • difficulties coping at work

Chronic fatigue syndrome

prevalence 0.5%, age 20-55

more common in females

proposed etiologies- viruses (EBV), immune dysfunction, endocrine -metabolic dysfunction - NOT proven

core symptom fatigue

sudden onset of symptoms

overlap other symptoms of FM

at least 6 months of persistent/recurring symptoms

Examination FM/CFS

Typically normal except for: soft tissue tenderness - FM > CFS tender cervical/axillary LN - CFS FM- assoc. joint hypermobility in about 1/4

• Masquerading conditions

• Inflammatory arthritis • CTD (esp SLE, Sjogren syndrome) • PMR • Hypothyroidism • Hyperparathyroidism • Vitamin D deficiency • Statin/other drug induced myopathy • Sleep apnoea • Caeliac disease

FBC, UE, LFT Ca, vit D , TFT , CK ESR to consider:

ANA <1:160 , ENA RF , ACCP x-rays hands/ feet caeliac serology iron studies

Investigations (also exclude contributing causes)

FM management

Exclude masquerading diseases

Treat comorbidities

Recognition of symptoms

Reassurance

Psychological

Physical

Pharmacological Goldenberg DL, et al. JAMA 2004;292:2388-95

FM - management

Treat comorbidities Sleep disturbance Depression

Recognition Giving patients a label... Acknowledgement of symptoms Framework to go forward ↑ health satisfaction,↓ symptoms1

1. White KP. Arthritis Rheum 2002;47:260-5

FM - management

Reassurance Not a destructive illness Improvement expected No other underlying malignant causes Identify realistic goals (symptom improvement rather than resolution) Psychological Pacing techniques Relaxation CBT

FM - management

Physical therapy “The most important aspect of treatment” Aerobic1 Graded (“pacing”) Hydrotherapy2

Patient needs to be aware: Typically experience a post-exercise flare of pain Improvements are slow (months-years)

1. Busch AJ. J Rheumatol 2008;35:1130 2. Gusi N. Arth Res Ther 2008;10:R24

FM - pharmacological management

Tricyclic antidepressants

SSRI, SNRI

Anticonvulsants

Analgesics

Other Dopamine agonists, Growth hormone, Pramipexole, Tropisetrone,

Transcranial electric nerve stimulation

FM - pharmacological management

Tricyclic antidepressants

Amitriptyline: 10-25mg nocte Evidence in several RCTs, meta-analyses1,2 ? Effective in 30% Benefits for sleep, ? Neural excitability Side-effects reduced with gradual dose introduction

1.Hannonen P. Br J Rheumatol 1998;37:1279

2.Heymann RE. Clin Exp Rheumatol 2001;19:697

FM - pharmacological management

SSRI Fluoxetine Variable evidence – support at high-dose (80mg), and with

amitriptyline at low-dose (20mg) Paroxetine Modest benefit in a single trial

SNRI Duloxetine 60- 120mg daily 3 RCTs demonstrating benefit - ↓ pain, ↑ function

Venlafaxine Conflicting results; benefit in open-label studies

Duloxetine in FM

Dual reuptake inhibitor Similar affinity for 5HT and NA reuptake inhibition May correct a functional deficit of 5HT and NA in FM

3 large RCTs1-3 Duloxetine at 60-120mg/d Improved pain and FIQ scores NNT for 50% improvement in pain = 10

Both in depressed/ non-depressed patients Reasonably well-tolerated Side effects: nausea, insomnia, dry mouth, constipation, headache

1. Arnold LM. Arthritis Rheum 2004;50:2974 2. Arnold LM. Pain 2005;119:5 3. Russell IJ. Pain 2008;136:432

Arnold LM. Pain 2005;119:5

FM - pharmacological management

Anti-convulsants Pregabalin α2δ calcium channel antagonist - ↓release of excitatory

neurotransmitters Evidence in 3 RCTs1-3

Commencing 75mg bd, increasing to 300mg bd max Improved pain, FIQ, sleep

NNT for 50% improvement in pain = 8.2 Side effects: somnolence, dizziness, weight gain, headache PBS-funded - neuropathic pain

1. Arnold LM. J Pain 2008;9:792 2. Mease PJ. J Rheumatol 2008;35:502 3. Crofford LJ. Pain 2008;136:419

Mease PJ. J Rheumatol 2008

Arnold LM. J Pain 2008

FM - pharmacological management

Analgesics Paracetamol Worth trialling in all patients (regular dosing)

Opiates -best avoided (tolerance, dependence, pain sensitation) Tramadol Some evidence alone/ in combination with paracetamol Caution if on SSRI/ TCA – serotonergic syndrome

Alternative therapy -acupuncture low to moderate evidence for pain and stiffness, EA>MA effects not maintained at 6 months follow up

Deare J Cochrane 2013

FM - management summary

The patients have to actively participate in their care Combined approach Education, Exercise, Psychotherapy, Medications Which medication? Amitriptyline, Pregabalin In patients with sleep disturbance

Duloxetine In patients with co-existent depression

Trial any/ all if no benefit with initial agent Evolution Combination therapies ? Tailored therapy

CFS - management

Recognition and reassurance

Physical therapy - graded - moderate evidence

CBT

Pharmacological therapy - disappointing

Alternative therapies - weak evidence

qigong and meditation (rhythmic breathing coordinated with slow, fluid movement)

massage therapy

thai chi