Fibromyalgia: are you a believer?

Transcription

1 Fibromyalgia: are you a believer? Shorin Nemeth, DO, FACOI Medical Director Comprehensive Pain Services Medical Director Oncology Palliative Care Providence Health and Services Portland, OR

2 Disclosures No relevant financial disclosures Off label use of medications will be discussed.

3 Overview: Historical Perspectives Epidemiology Pathophysiology Clinical Manifestations Diagnosis Treatment Options

4 In the beginning: Appears to have been described in the book of Job Originally called Rheumatism Fibrositis by Gowers in 1904 Fibromyalgia 1976 First validated with a study in 1981 American College of Rheumatology Criteria 1990 Inanici FF, Yunus MB. History of Fibromyalgia: Past to present. Cur Pain Headache Rep Oct 8 (5):369-78

5 Case: 28 y/o woman with right sided paresthesias Intermittent shock sensations Headaches Tingling of extremities 6 month onset Humanillness.com accessed 4/19/18

6 Epidemiology Prevalence estimated at 6.4% in the US using ACR 2010 criteria 7.7% women 4.9% men Estimated that diagnosis with ACR 1990 criteria will miss 50% of patients Estimated to cost $9 billion annually (US)

7 Epidemiology F>M 4:1 Race? African American women > Caucasian women Socioeconomic status and education >race Age Women Peak Prevalence women years old Genetics: Suggestive, but not conclusive 1 st degree relatives of patients with FM are 8.5 times more likely to have FM than RA Several genes being studied.

8 Pathophysiology Nervous system Central Sensitization Syndrome Overlaps with Chronic Fatigue Syndrome Irritable Bowel Syndrome Chronic Pelvic Pain Temporomandibular Joint Pain Tension/Migraine Headaches Post Traumatic Stress Disorder Multiple Chemical Sensitivity Periodic Limb Movement/Restless Leg syndrome Interstitial Cystitis Hypermobility Syndrome

9 Pathophysiology Co-exists with high frequency with Rheumatoid Arthritis Systemic Lupus Erythematosus Chronic Hepatitis C

10 Pathophysiology Central Sensitization Syndrome Patients become overwhelmed with stimuli Pain Odor Heat Noise Noxious stimuli are misperceived as pain

11 Pathophysiology Implicated Mechanisms NMDA receptor Increased levels of substance P Higher levels of insular glutamate Decreased endogenous pain inhibition Low serotonin levels Suppressed release of dopamine from the limbic system

12 Pathophysiology NMDA receptor implicated in central sensitization 11/1/14

13 Pathophysiology Accessed 11/1/14

14 Pathophysiology 11/1/14

15 11/1/14

16 Pathophysiology Remember this: Hypothalamic Pituitary Axis (HPA) dysregulation Deficiency in inhibitory chemicals Serotonin Norepinephrine GABA? Dopamine Out of control pain pathways Thought to involve the NMDA receptor

17 Or Just Remember This: Overcomingsocialanxiety.com Accessed 4/19/18

18 Clinical Manifestations: Widespead pain Fatigue Cognitive dysfunction Non-restorative sleep

19 Differential diagnosis Systemic Lupus Erythematosus (SLE) Hepatitis C Polymyalgia Rheumatica Endocrine abnormality Multiple Sclerosis/neurological disorder Psychiatric Hypochondriasis Malingering Somatoform Pain Disorder

20 Diagnostic Criteria Wolfe et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis and Rheumatism. Feb :2 ( )

21 Wolfe et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis and Rheumatism. Feb :2 ( )

22 Diagnostic Criteria Wolfe, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care and Research. May :5 ( )

23 Widespread Pain Index In the last week, in how many areas has the patient had pain? 1. Shoulder girdle, Left 2. Shoulder girdle, Right 3. Upper arm, Left 4. Upper arm, Right 5. Lower arm, Left 6. Lower arm, Right 7. Hip (buttock, trochanter), Left 8. Hip (buttock, trochanter), Right 9. Upper leg, Left 10. Upper leg, Right 11. Lower leg, Left 12. Lower leg, Right 13. Jaw, Left 14. Jaw, Right 15. Chest 16. Abdomen 17. Upper back 18. Lower back 19. Neck

24 Symptom Severity Score (max of 12) 0 No problem 1 Slight or mild 2 Moderate 3 Severe: pervasive, life disturbing Fatigue Waking unrefreshed Cognitive Somatic

25 Somatic Symptoms Muscle Pain Irritable Bowel Syndrome Fatigue/tiredness Thinking or remembering problem Muscle weakness Headache Pain/cramps in abdomen Numbness/tingling Dizziness Insomnia Depression Constipation Pain in the upper abdomen Nausea Nervousness Chest pain Loss of appetite Rash Sun sensitivity Blurred Vision Fever Diarrhea Dry mouth Itching Wheezing Raynaud s phenomenon Hives/welts Ringing in ears Vomiting Heartburn Oral ulcers Loss/change in taste Seizures Dry eyes Shortness of breath Hearing difficulties Easy bruising Hair loss Frequent urination Bladder spasms Painful urination

26 Criteria Widespread Pain Index (WPI) 7 and symptom severity (SS) scale score 5 or WPI 3-6 and SS Scale score 9 Symptoms present at similar level for 3 months Patient does not have a disorder that would otherwise explain the pain

27 Case: 28 y/o woman with right sided paresthesias Intermittent shock sensations Headaches Tingling of extremities 6 month onset Humanillness.com accessed 4/19/18

28 Workup: ESR, CRP Mg TSH Vitamin D ANA HbA1C Anti CCP, Rheumatoid Imaging as needed Factor EMG/NCV if indicated Hepatitis Panel Sleep Study if CBC Indicated Behavioral Medicine? Neuroimaging Iron Studies

29 Or Talk to the patient Abcnews.go.com accessed 4/19/18

30 Treatment: Physical Sleep Pharmacotherapy Behavioral

31 Management Simple Cases: Patient Education Treat comorbid conditions Obstructive Sleep Apnea Depression Anxiety Aerobic Exercise program Drug Monotherapy Amitriptyline/TCA Duloxetine (Cymbalta) or venlafaxine (Effexor) Pregabalin (Lyrica) Milnacipran (Savella)

32 Management Patient Education: Fibromyalgia is real Reassure patient that other potential causes have been evaluated Sleep Hygiene Encourage aerobic exercise

33 Management: Sleep HUNT study 1 12,350 women Women without history of musculoskeletal pain are 5 times more likely to develop Fibromyalgia if co-existing sleep disorder 11 Times more likely to have RLS 2 ACR diagnosis emphasizes importance of sleep impairment 1. Mork PJ, Nilsen TIL. Sleep problems and risk of fibromyalgia: longitudinal data on an adult female population in Norway. Arthritis and Rheumatism. January (1): Larson NF. Patients with fibromyalgia 11 times more likely to have restless legs syndrome.(from J Clin Sleep Med 2010; ). Accessed 11/2/14

34 Management: Sleep Sleep Study Counseling on sleep hygiene Have patient keep a sleep diary for 2 weeks ***Cognitive behavioral therapy for Sleep*** Judicious use of pharmacotherapy

35 Management: Exercise Aerobic Exercise 30 minutes at least 3 times weekly 220-Age= Maximum Heart Rate Target heart Rate is about 0.80 x Maximum Heart Rate Start with low impact Swimming Elliptical Rowing Stationary Bike I start patients with 3 minutes 3 times weekly and increase every few weeks to goal of 30 minutes Yoga and Tai Chi have also shown benefit

36 Management: Pharmacotherapy Clinical Caveat Many Pt s will have multiple drug sensitivities Start low and go slow Therapeutic Classes Analgesics TCA s SNRI s Antiepileptic therapies Muscle relaxants

37 Management: Pharmacotherapy Clinical Pearls Remember: Fibromyalgia is a pain processing disorder Primary problem is thought to be lack of inhibition of pain pathways Approach to management is aimed at increasing pain pathway inhibition Similar to diabetes, pt s need long term controlling agents, not just rapid acting medications

38 Management: Analgesics Essentially for short term or break through use NSAIDS and Acetaminophen Limited efficacy unless inflammatory component Weak opioids: Ultram (tramadol) Serotonergic and norepinergic properties Nucynta (tapentadol) Weak mu agonist similar to tramadol More norepinephrine than tramadol Still rather expensive

39 Management: Muscle Relaxants May help with sleep, but goal is again for short term use NO SOMA Flexeril (cyclobenzaprine) Metabolized to a TCA Use Caution if also using TCA s Robaxin (methocarbamol) Zanaflex (tizanidine) Centrally acting alpha-2 agonist May drop Blood Pressure Concurrent quinolones increase tizanidine blood concentrations 10 fold Baclofen Must be tapered off. Abrupt cessation may cause Seizures.

40 Management: Antidepressants Effexor (venlafaxine) SNRI No studies to prove efficacy Minimum effective dose for pain usually 150mg daily May cause hypertension Cymbalta (duloxetine) SNRI Proven efficacy at doses up to 60 mg daily. No benefit at higher doses Savella (milnacipran) SNRI May be titrated up to 100mg BID Pristiq (desvenlafaxine)?

41 Management: Tricyclics Lower doses seem to be most effective Consider mg QHS Elavil (amitriptyline) Pamelor (nortriptyline) Norpramin (desipramine)

42 Management: Antiepileptics Alpha-2/Delta calcium Channel modulators Neurontin (gapabentin) Titrate to maximum of 2400mg/day May start at 100 or 300mg QHS Lyrica (pregabalin) Titrate to maximum of 600mg/day May start at 25 or 50mg QHS Topamax (topiramate)? Remember to start at low doses initially

43 Management: Other Pure opioid agonists Problematic in Fibromyalgia Do not use Cannabinoids May have some benefit, particularly with sleep Further studies needed Benzodiazepines Generally avoid Use with caution if other treatments have failed

44 Management: other Under Investigation Mirapex (Pramipexole) Improved pain Seroquel (Quetiapine) Improved depression>pain Naltrexone Improved pain and satisfaction with life Sodium Oxyburate Improved sleep, pain, and fatigue Abuse potential Transcranial Magnetic Stimulation Improved pain and depression

45 Management: Other Acupuncture: Unclear. May be beneficial Moving meditation Tai Chi Yoga Improved pain, fatigue, mood, pain catastrophizing, and other coping.

46 Management: Behavioral Many patients have comorbid depression Many patients have also lost coping mechanisms Cognitive Behavioral Therapy has shown beneficial for Pain related to Fibromyalgia Sleep Disorders Mindfulness training Effective in chronic pain

47 Summary Fibromyalgia is no longer diagnosed with tender points only It is a condition with pain, sleep, cognitive, and behavioral manifestations. Simple cases can be treated with education, monotherapy, and aerobic exercise More complicated cases will involve multidisciplinary treatments and specialty referrals Underlying pathophysiology is lack of pain and central nervous system inhibition.

48 Bibliography Boomershine CS. Fibromyalgia. In Medscape Diamond SH (Ed). last accessed 11/2/14 Goldenberg DL. Clinical Manifestations and diagnosis of fibromyalgia in adults. In UpToDate Schur PH, Romain PL (Ed), UpToDate, Waltham, MA. Accessed 10/25/14 Goldenberg DL. Pathogenesis of fibromyalgia. In UpToDate Schur PH, Romain PL (Ed), UpToDate, Waltham, MA. Accessed 10/25/14 Goldenberg DL. Initial treatment of fibromyalgia in adults. In UpToDate Schur PH, Romain PL (Ed), UpToDate, Waltham, MA. Accessed 10/25/14 Goldenberg DL. Treatment of fibromyalgia in adults not responsive to initial treatment. In UpToDate Schur PH, Romain PL (Ed), UpToDate, Waltham, MA. Accessed 10/25/14 Inanici FF, Yunus MB. History of Fibromyalgia: Past to present. Cur Pain Headache Rep Oct 8 (5): Larson NF. Patients with fibromyalgia 11 times more likely to have restless legs syndrome.(from J Clin Sleep Med 2010; ). Accessed 11/2/14 Mork PJ, Nilsen TIL. Sleep problems and risk of fibromyalgia: longitudinal data on an adult female population in Norway. Arthritis and Rheumatism. January (1): Wolfe et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis and Rheumatism. Feb :2 ( ) Wolfe, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care and Research. May :5 ( )

49 Thank You!