Fibromyalgia Update. Presenter: Manfred Harth MD FRCPC

Transcription

1 Fibromyalgia Update Presenter: Manfred Harth MD FRCPC

2 Fibromyalgia Update Manfred Harth MD FRCPC

3 Disclosures Member Pfizer Canada Medical Advisory Committee on Lyrica (till April 2013) Abbvie : Payment for lecture to medical staff Strathroy Hospital on early Rheumatoid Arthritis (2014).

4 Objectives Describe the clinical features of fibromyalgia and the approach to diagnosis. Outline the proposed pathogenesis of fibromyalgia. Discuss the efficacy and describe the side effects of therapeutic modalities and agents used

5 Ontario Rheumatologists Survey (80 responses) Accept new referrals : 60% FM is a psychosomatic illness : 55.1% FM is a physical illness : 44.9% Rheumatologists to retain ownership : 29.1% Main care providers to be : Rheum : 6.3%; Psych: 5%; FP: 88.8% S Ghazan-Shahi et al Clin Rheumatol 2012: 31:

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8 Associated Symptom Disorders and Signs Migraine headaches Irritable bowel syndrome Irritable bladder Sensitivity to odours, light, noise Anxiety Depression Vulvodynia > 11 Tender points (allodynia)

9 Associated with: Rheumatoid Arthritis SLE Ankylosing Spondylitis Hepatitis C AIDS Endometriosis Multiple Sclerosis Lyme Disease?

10 Epidemiology Widespread. Occurs in both economically advanced as well as in 3 rd world countries e.g. Bangladesh. Prevalence 2-6%. F/M : 10/1 to 3/2.

11 London, Ontario Adult Prevalence : 3.3% Women : 4.9% ; Men : 1.6% White KP, Speechley M, Harth M, Ostbye T. J Rheumatol 1999 ; 26:

12 PREVALENCE OF FMS (London,Ont) Age Group Women Men % 1.0% % 1.9% % 2.4% % 2.5% % 1.2% % 0.0% % 0.0%

13 Smythe HA, Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome. Bull Rheum Dis ;28(1):928-31

14 ACR Classification Criteria Wolfe F 1, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum Feb;33(2):160-72

15 At least 3 regions of chronic pain (> 3 months) : 1 above the waist ; 1 below the waist ; 1 on each side of the body ; 1 in the centre of the body

16 + > 11/18 tender points

17 Occiput (2) - at the suboccipital muscle insertions. Low cervical (2) - at the anterior aspects of the intertransverse spaces at C5- C7. Trapezius (2) - at the midpoint of the upper border. Supraspinatus (2) - at origins, above the scapula spine near the medial border. Second rib (2) - upper lateral to the second costochondral junction. Lateral epicondyle (2) - 2 cm distal to the epicondyles. Gluteal (2) - in upper outer quadrants of buttocks in anterior fold of muscle. Greater trochanter (2) - posterior to the trochanteric prominence. Knee (2) - at the medial fat pad proximal to the joint line

18 Digital palpation should be performed with an approximate force of 4 kg/cm 2 (Or until distal 1/3 of thumb blanches)

19 F Wolfe et al Arthritis Care Res 2010; 62:600-10

20 Widespread Pain Index (WPI) Total :19 regions Pain for > 1 week

21 Symptom Severity (SS) score Present for 3 months Level of severity for each of 3 over past 1 week

22 Add Somatic Symptoms : Rate these in terms of severity : 0-3

23 Total Possible SS Score : 12 WPI Range :0-19 FM DIAGNOSIS IF : SS > 5 < 9 and WPI > 7 or SS > 9 and WPI > 3 SEVERITY SCORE: 5-12

24 Candidate genes : Pathophysiology These include serotonin transporter genes, serotonin receptor genes, adrenergic receptor genes, dopamine receptor genes, catechol-o-methyl - transferase genes, apolipoprotein e4 genotypes.

25 Predisposing and Triggering Factors Childhood abuse PTSD Injuries e.g.mvc Illness Obesity Lack of exercise

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27 Caudate Nucleus Insula

28 fmri response to painful heat Normal Control Fibromyalgia DB Cook et al J Rheumatol 2004; 31:364-78

29 Substance P in CSF Controls FMS Adapted from I J Russell et al Arthritis Rheum 1994;37:

30 Nerve growth factor in CSF Controls FMS Adapted from SL Giovengo et al J Rheumatol 1999;26:1564-9

31 Wind-up (Temporal summation) with heat R Staud et al PLoS ONE 2014;9 : 1-8

32 Normal controls show activation of rostral anterior cingulate cortex (A), and pulvinar nucleus of thalamus (B) during painful stimulation. KB Jensen et al Pain 2009;144 :95-100

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34 We know that patients with FM suffer from anxiety and depression. Their pain is clearly due to these changes in mood

35 Response to Pain in FM-Effects of Mood Disorder fmri brain activity in a patient responding to a painful stimulus (thumb pressure) K Jensen et al Arthritis Rheum 2010; 62:

36 The 3 regression analyses in which depressive symptoms, anxiety or catastrophizing scores were used as covariates showed no significant results, i.e brain activity during pain was not modulated by levels of depressive symptoms, anxiety, or catastrophizing.

37 ME Robinson et al J Pain 2011;12:436-43

38 Recently several groups have reported small fibre (C fibre) neuropathy in up to 50% of patients with FM.

39 Brain activity and sleep in FMS Half the patients with FMS have phasic alpha sleep(compared to 7% of controls). All of these have a non-refreshing sleep.* * S Roizenblatt et al Arthritis and Rheum 2001; 44:222-30

40 Therapy Pharmacologic Non-pharmacologic

41 Well Documented Pharmacologic Treatments 1. Tricyclic Antidepressants (TCA) The best studied one is amitriptyline. Doses should not exceed 50 mg/day Usually given at hs. Cyclobenzaprine (not an antidepressant). Doses used mg daily. Try low doses (< 5 mg) to improve sleep Problems : Tachyphylaxis? Excessive drowsiness Weight gain

42 2. Duloxetine (Cymbalta) A SNRI antidepressant with pain relieving effects in FM and other conditions.dose range : mg/day Effect on Pain L Arnold et al Prim Care Companion J Clin Psychiatry. 2009; 11(5):

43 E Choy et al Clin Rheumatol 2009; 28:

44 Pregabalin (Lyrica) Blocks α 2 δ subunit in Ca channel Has analgesic, anxiolytic, and anticonvulsant properties. Reduces Ca influx at nerve terminals. Reduces release of substance P, noradrenaline, glutamate at nerve terminals.

45 M E T A A N A L Y S I S S Straube et al Rheumatology 2010 ; 49:706-15

46 Adverse Effects Drowsiness Confusion Weight gain Peripheral edema

47 Tramadol and Acetaminophen T and A Placebo RM Bennett et al Am J Med 2003;114:537-45

48 Serotonin syndrome.reported with high doses of Tramadol + high doses of SSRIs,SNRIs, TCA, MAOIs Adverse Effects Drowsiness Constipation Itchiness

49 Milnacipran ( Savella ) a SNRI, not used in Canada

50 Non-Pharmacologic Therapy Low-impact aerobic or strengthening exercises Cognitive behavioural therapy (CBT)

51 Women with FM FIQ VAS Pain Pre-exercise Post-exercise CG EG CG EG P<0.001 P<0.001 CG : Control Group EG : Exercise Group Adapted from : PA Latorre et al. Clin Exp Rheumatol 2013; 6 Suppl 79 : S72-89

52 Tai Chi C Wang et al N Engl J Med 2010;363:743-54

53 Cognitive behavioural therapy (CBT) 3 FM groups (40-43) CBT, OBT, Attention placebo (AP) CBT:focus on patient thinking, problem solving, relaxation. Operant-behavioural therapy : focus on pain behaviour rather than on thought. 15 weekly sessions of 2 hrs each Kati Thieme,Dennis Turk,Herta Flor; Arthritis Care Res.2007; 57:830-6

54 p<0.001 % ge with clinically significant reduction or increase in pain at 12 months p<0.005 % ge with clinically significant reduction or increase in physical impairment at 12 months

55 Weak evidence for : Nabilone Pramipexole Gabapentin Quetiapine Sodium oxybate (ɣ hydroxybutyrate, xyrem) Growth hormone Fluoxetine Electro-acupuncture

56 NO EVIDENCE FOR : NSAIDS Steroids Narcotics Tender Point Injections Lidocaine IV Marijuana Various Diets Guaifenesin Other Antidepressants (for pain) Acupuncture

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