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