FIBROMYALGIA
FIBROMYALGIA
• 1ST defined by ACR criteria1990
• 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 and below the waist.
In addition, axial skeletal pain (cervical spine or anterior
chest or thoracic spine or low back) must be present.
Shoulder and buttock pain is considered as pain for each
involved side
• Pain in 11 of 18 tender points on digital palpation (4kg
force), must be described as painful, not tender
• Widespread pain must have been present for at least 3
months
Fibromyalgia
• Redefined by ACR 2010 without emphasis on
tender points:
• A patient satisfies criteria if the following 3
conditions are met:
• 1 Widespread Pain Index (WPI) of at least 7
and symptom severity scale score (SS) at least
5, or WPI 3-6 and SS scale at least 9
• 2 Symptoms present at a similar level for at
least 3 months
• 3 The patient does not have another disorder
that would otherwise explain the pain
Fibromyalgia: WPI
• Note the number of areas in which the patient has had
pain over the last week. In how many areas has the
patient had pain? Score between 0 and 19
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Shoulder girdle, L and R (2)
Upper arm L and R (2)
Lower arm L and R (2)
Hip (buttock, trochanter ) L and R (2)
Upper leg L and R (2)
Lower leg L and R (2)
Jaw L and R (2)
Chest
Abdomen
Upper back
Lower back
neck
Fibromyalgia SS scale score
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Fatigue
Waking unrefreshed
Cognitive symptoms
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For each of the 3 symptoms, indicate the level of severity over the 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
0
no symptoms
1
few symptoms
2
a moderate number of symptoms
3
a great deal of symptoms
SS scale score is the severity of the 3 symptoms (fatigue, waking unrefreshed,
cognitive symptoms) plus the severity of somatic symptoms, final score between 0
and 12
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Fibromyalgia Somatic Symptoms
• Muscle pain, irritable bowel, fatigue/tiredness, thinking or
remembering problem, muscle weakness, headache,
pain/cramps in the abdomen, numbness/tingling,
dizzyness, insomnia, depression, constipation, pain in
the upper abdomen, nausea, nervousness, chest pain,
blurred vision, fever, diarrhoea, dry mouth, itching,
wheezing, Raynauds, hives/welts, ringing in the 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, bladder
spasms
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management
• 46 recommendations
• FM represents a composite of symptoms, with body pain
present as the pivotal symptoms. There is a spectrum of
severity which associates with functional outcome, and
fluctuating symptoms over time.
• Diagnosis is clinical, not one of exclusion, not one
requiring specialist confirmation, and requires limited
laboratory testing. A physical examination is required to
exclude other conditions presenting with body pain, but
tender point examination is not required to confirm the
diagnosis. Excessive laboratory testing is strongly
discouraged
• Ideal care is in the primary care setting and should be
multimodal
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management
• Focus on non pharmacological and
pharmacological strategies to reduce symptoms
and improve function
• Patient must be an active participant
• No ideal pharmacological treatment
• Emphasis on healthy lifestyles, maintenance of
function including retention in the workforce,
periodic reassessment re need for continuing
any medication, side effects of treatments and
new symptoms
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management
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Pain
Fatigue
Nonrestorative sleep
Cognitive dysfunction
Mood disorders
Pain related somatic symptoms (irritable bowel,
migraine, headaches, severe menstrual pain,
lower urinary Tract symptoms, myofascial pain,
TMJ pain)
• Non-pain related symptoms (sexual dysfunction,
increased risk of post traumatic stress disorder)
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management
• Dysaesthesia (sensitivity to light touch)
• Allodynia (unpleasant sensation or pain
after a non-painful stimulus)
• No objective neurological findings
• Expression of pain or pain behaviours may
be present but should not imply faking of
symptoms
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management
• FBC
• ESR
CRP
• TSH
• CPK
• Low Vit D level supplementation has no effect on
FM pain
• Low titre ANA present in around 10% and should
only be tested on specific clinical suspicion
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management: DD
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Hypothyroidism
Early inflammatory arthritis or CTDs
PMR
Myositis
Multiple sclerosis
Neuropathies
Myopathies
Drugs: statins, aromatase inhibitors,
bisphophonates
• Remember that FM can co-exist with other conditions
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management: Causes
• Unknown
• Abnormalities in pain processing at peripheral,
central and sympathetic NS and hypothal-pitadrenal levels
• Changes on functional MRI and SPECT brain
scans, increased substance P in the CSF
• Family studies suggest some genetic
predisposition with up to 26% relatives reporting
widespread pain, but no clear gene associated
with FM
• Psychosocial distress can predict onset
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management: Management
• No cure
• Education and reassurance of no harm
with physical activity
• Good social support and healthy lifestyle
• Treatment of psychological stress
including group therapy, motivational
interviewing eg spaced phone calls to
encourage exercise regimes, CBT
• Distraction therapy
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management: Management
• No evidence for alternative medicines
including acupuncture, chiropractic
manipulations
Fibromyalgia: 2012 Canadian Guidelines for
diagnosis and management: Management
• Paracetamol never formally examined
• NSAIDs tried
• Tramadol showed positive effects on pain and
quality of life
• No convincing evidence of benefit from codeine,
but often tried
• Strong opioids not recommended
• Tricyclic antidepressants
• SNRI’s: duloxetine 60-120mg/day
• gabapentinoids
RHEUMATOID ARTHRITIS
Aggressive regimes have long replaced the old
treatment paradigm of 6 months NSAIDs then
cautious introduction of DMARDs
NICE recommend combination therapy from the
beginning, including steroids
BNF outdated as says drugs are contraindicated
together due to potential drug interactions
Preference for 2 DMARDs with steroid initially,
trying to phase out steroids over several months,
but patients often resistant to such initial
polypharmacy
RA
DMARDs
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Methotrexate (MTX) oral or sc (to 30mg)
Sulfasalazine (SSZ)
Leflunomide
Hydroxychloroquine
Azathioprine (Aza or AZT)
Ciclosporin
Gold (IM)
Penicillamine
RA disease assessment
• DAS 28 is the currently accepted
European wide (and NICE) disease score
• 28 tender joints
• 28 swollen joints
• ESR or CRP
• Patient VAS
• Complicated formula requires a special
calculator
RA disease assessment
• CDAI: Clinical Disease Activity Score
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28 tender joints
28 swollen joints
Patient VAS
Physician VAS
Add swollen and tender score to the 2 global
scores (0-10 each)
• Range 0-76, <10 is low activity, 10.1-22 is
moderate, 22.1-76 high activity
RA disease assessment
• SDAI: Simplified Disease Activity Index
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Numerical sum of the following 5 scores:
28 tender joints
28 swollen joints
Patient VAS (0-10)
Physician VAS (0-10)
CRP in mg/dl ie normal <1mg/dl
RA: Biologics
• Anti-TNFs:
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infliximab (IV)
etanercept
adalimumab
certrolizumab
golimumab
best response when used with MTX (or another
DMARD) but all but infliximab can be used alone
RA: Biologics
• Rituximab: anti-CD20
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best response if RF or
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anti-CCP positive
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recommended with MTX
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2nd choice in NICE guidance
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unless RF/CCP negative
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only funded if response>6/12
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RA: Biologics
• TOCILIZUMAB
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Anti-IL-6
Best data on use without DMARD
NICE accept it as potential 1st biologic
Currently only allowed locally 1st if MTX
intolerant
R: BIOLOGICS
• ABATACEPT
• Fusion protein (Fc of IgG1 fused to extracellular domain
of CTLA-4)
• CTLA-4: Cytotoxic T Lympocyte Antigen 4 (or CD152) is
found on surface of helper T cells and down regulates T
cells Similar to CD28 which is a co-stimulatory protein
activateingT cells through binding to CD 80 and CD 86
• Abatacept binds to CD80 and CD86 on APC with higher
affinity and thus inhibits the co-stimulation of T cells