Transcript Fibromyalgia :: Fouch

Fibromyalgia
Erin Fouch
October 31, 2005
Diagnostic Criteria
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American College of Rheumatology
Diagnostic Criteria (1990)1
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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.
Tender Points
http://fibromyalgia.ncf.ca2
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Appropriate pressure is 4 kg/cm– approximately
enough to turn the examiner’s nailbed white.
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.
Epidemiology
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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
Case Cont’d
ROS: Positive for daytime fatigue, constipation,
and occasional palpitations.
PMH: None.
Meds: Acetaminophen prn
FH: Mother has RA, sister has hypothyroidism.
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.
Case Cont’d
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What is your differential diagnosis?
What further work-up does she need?
Differential Diagnosis
1.
Polyarticular arthritis
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2.
Endocrine disorders
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3.
Rheumatoid arthritis
SLE
Polymyalgia rheumatica
Hypothyroidism
Hyperparathyroidism (hypercalcemia)
Myopathies
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Polymyositis
Rhabdomyolysis
Differential Diagnosis
4.
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Neuropathies
Depression
Chronic fatigue syndrome
Myofascial pain syndrome
Anemia
Case Cont’d
What further work-up does our patient need?
Diagnostic Evaluation
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Careful history and physical
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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)
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Diagnostic Evaluation
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Generally NOT recommended
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ANA, Rheumatoid factor
Diagnostic Evaluation
Differentiating FM from other disorders
RA
Elevated RF, ? ESR, joint
swelling/deformity, systemic
symptoms
SLE
Systemic symptoms, ESR
PMR
Stiffness, ESR. Usually older
patients.
Myositis/Rhabdo
Weakness, elevated CK
Depression
Tender points negative
Myofascial pain syndrome
Localized pain
Chronic fatigue syndrome
Fatigue > pain
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.
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.
Overlapping Syndromes and
Symptoms
Common Comorbidities:
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Rheumatoid arthritis
(12%)
SLE
Hepatitis C
Myofascial pain
syndrome
TMJ
IBS
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Osteoarthritis (7%)
Depression
Migraine headaches
OSA
Restless legs
Overlapping Syndromes and
Symptoms
Common symptoms
 Fatigue
 Subjective joint/muscle
swelling
 Difficulty sleeping
 Night sweats
 Dyspnea
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Palpitations
Pelvic pain
Dysmenorrhea
Non-cardiac chest pain
Diarrhea/constipation
(IBS)
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.
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.
Depression and Fibromyalgia
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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
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.
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
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.
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 welltolerated.
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
Treatment of Fibromyalgia
Medications-- SSRIs
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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
Treatment of Fibromyalgia
Medications– Tricyclic antidepressants
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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
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
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Treatment of Fibromyalgia
Medications with “strong” or “moderate”
evidence for efficacy3
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Amitriptyline
Cyclobenzaprine
Tramadol
Fluoxetine
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Venlafaxine
Duloxetine
Pregabalin
Treatment of Fibromyalgia
Ineffective Medications
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Corticosteroids
Opioids
NSAIDs
Benzodiazepines
Guaifenesin
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Levothyroxine
Cacitonin
Melatonin
Magnesium
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.
Natural history of fibromyalgia
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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.
Fibromyalgia: take-home points
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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
References
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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.