Fibromyalgia vs Polymyalgia Rideumatica - MemberClicks...“Fibromyalgia vs. Polymyalgia” Richard...

“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO

POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019

Fibromyalgia vs Polymyalgia

Richard A. Pascucci D.O., F.A.C.O.I

PCOM Professor Emeritus

#POMA19 #ChooseKnowledge

Disclosures

⚫ I have no relevant financial relationships or

conflicts of interest to disclose.


MONOARTICULAR POLYARTICULAR

Crystals Infections CTD Seronegative Spondylo

Gout Septic Arth. RA A.S.

CPPD Bursitis SLE Reiter’s

HADD Lyme PSS Psoriatic Oligo.

Oxalate Fungus PM/DM Colitic

TB Vasculitis Yersinia

MONO/Oligo

NON-ARTICULAR ENDOCRINE & DEGENERATIVE

METABOLIC

Primary

Fibromyalgia Thyroid Osteoarthritis

Bursitis Crystals DISH Secondary

Tendinitis Amyloid Mono.

RSD Aseptic Necrosis

PMR METABOLIC BONE DISEASE Charcot’s

Osteoporosis

Paget’s

Osteomalacia

Hyperpara

CLINICAL CLASSIFICATION OF THE RHEUMATIC

DISEASES


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NON-ARTICULAR RHEUMATISM

Fibromyalgia (Fibrositis)

Bursitis/Tendinitis

Tenosynovitis

Viral Myalgia

Hematoma (Muscular)

Reflex Dystrophies

Referred Pain

Nerve Entrapment

Pyschogenic Rheumatism

Phlebitis

Panniculitis#POMA19 #ChooseKnowledge

CASE PRESENTATION

A 35 year old female presents to the office with the

complaint of “Pain All Over”. Her multiple aches and

pains have been present for at least 18 months and are

associated with AM stiffness for at least 2 hours.

Physical exam fails to reveal any true joint abnormality

and laboratory data is unremarkable. She has associated

sleep disturbance and weather change aggravates her

symptoms.


Fibrositis

Myositis

Myofascial pain syndrome

Myofasciitis

PRIMARY FIBROMYALGIA SYNDROME

• No Inflammation

• Consistent symptom spectrum

• No underlying cause


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FIBROMYALGIA

Non-articular rheumatism characterized by:

1. Chronic musculoskeletal aches, pains

and stiffness, mostly in muscles,

articular and periarticular areas.

2. “Tender (trigger) points” – exaggerated

tenderness in specific spots.

3. Absence of articular pathology.


FIBROMYALGIA

1. DEFINITION

2. CLINICAL FEATURES

a) Age

b) Sex

c) Primary vs, Secondary

d) Aggravating Conditions

3. HISTOLOGY

a) Skin Biopsy (“Triggers”)

b) Immunofluorescence

4. ASSOCIATED CLINICAL PROBLEMS

- Other “Soft Tissue” problems


PFS: MODULATING FACTORS

AGGRAVATING FACTORS

Cold or humid weather

Non-restorative sleep

Physical/mental fatigue

Excess physical activity

Physical inactivity

Anxiety/stress

RELIEVING FACTORS

Warm/dry weather

Hot shower/bath

Restful sleep

Moderate activity

Stretching exercises

Massage


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PFS: EXAMINATION

POSITIVE

Multiple Tender

Points

Mild soft tissue

swelling (fingers)

Skin pinch

Tenderness

Hyperemia of skin

NEGATIVE

Muscle weakness

Neurologic examination

Joint examination


ACR CRITERIA FOR FIBROMYALGIA

(1990)

1. History of Widespread Pain

- Left and right side, above and below waist.

- Axial skeletal pain (cervical, thoracic, anterior

chest or low back) also present.

2. Pain in 11 of 18 tender point sites

Occiput Lateral Epicondyle

Low Cervical Gluteal

Trapezius Greater Trochanter

Supraspinatus Knee

Second Rib



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⚫ ACR Criteria (Revised 2010)

⚫ - Supplement 1990 Criteria, not replace

⚫ ** Includes Sleep Disturbance

⚫ -Widespread Pain Index (WPI) -7/19 areas

⚫ -Symptom Severity (SS) Score (0-3 scale

⚫ for fatigue, cognitive Sx and

⚫ awakening unrefreshed) + 0-3 for Somatic

⚫ symptoms for a Total Score of 0-12


CRITERIA FOR DIAGNOSIS

OF FIBROMYALGIA

1) Widespread aching >3 months

2) Local tenderness at 12 of 14 specified sites

3) “Skin roll” tenderness in upper scapular region

4) Disturbed sleep

5) Normal Lab (ESR, SGOT, RF, ANA, CPK, and SI)


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DIFFERENTIAL DX. of FIBROMYALGIA

1) PSYCHOGENIC RHEUMATISM

2) RA OR OTHER CTD

3) PALINDROMIC RHEUMATISM

4) OSTEOARTHRITIS

5) POLYMYALGIA RHEUMATICA

6) HYPOTHYROIDISM


LABORATORY DATA (FIBROMYALGIA)

1) CBC

2) SED. RATE (ESR)

3) CMP

4) SEROLOGIES

5) EEG, EMG

6) BIOPSY


ETIOLOGY (FIBROMYALGIA)

1) SLEEP DISTURBANCE

a) Non-REM

b) Alpha Intrusion

2) ?METABOLIC DERANGEMENT

a) Serotonin (Brain)

b) Tryptophan

3) ANXIETY AND/OR DEPPRESSION


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MANAGEMENT OF FIBROMYALGIA

1) REASSURANCE

2) ORGIN OF PAIN – explain

3) RELIEF OF MECHANICAL STRESSES – exercise

4) MEDICAL TREATMENT

a) NSAID

b) Heat, Massage, Relaxation, ?OMT

c) Antidepressants

d) Injections

e) Systemic Steroids – Relatively CI

f) Avoid Narcotics!

g) Experimental – Acupuncture, TENS, etc.


ADDITIONAL THERAPIES

SSRIs - ? EFFECT ON PAIN

TRAMADOL ↓ PAIN IN CONTROLLED TRIAL

(100-400 MG/day)

DULOXETINE 10-60mg/day (SNRI)

PREGABALIN—Analogue to GABA-ion channel modulator

UNCONTROLLED TRIALS

A) Guafenesin

B) Valerian Root

C) Ginseng

D) Melatonin

E) DHEA

4) NO SUPPORTIVE DATA ON TYLENOL OR NSAIDs

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Additional Therapies (Con’t)

⚫ -Quetiapine (Seroquel)—may benefit but

⚫ may cause weight gain

⚫ -Nabilone (Cesamet)—Cannabinoid

⚫ -Memantine (Namenda)

⚫ -Pramipexole (Mirapex)-Dopamine

⚫ promoter

⚫ -Xyrem-Use in Narcolepsy (Schedule III)


COMBINATION THERAPY OF

FIBROMYALGIA

“A Randomized Double-Blind Crossover Trail

of Fluoxetine and Amitriptyline in the Treatment

of Fibromyalgia”

D.L.GOLDENBERG, ET AL: A&R 1996; 39: 1852

Conclusion: Combination Better than either Drug Alone


Combination Therapy

⚫ Utilization of an Anti-Epileptic (e.g.

Pregabalin) plus an Anti-Depressant (e.g.

Amitriptyline or an SNRI) may yield

improvement in pain and fatigue

⚫ --Pain 2016 Jul; 157 (7): 1532


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GROWTH HORMONE

(NUTROPIN ®)

Dosage

0.006 - 0.025 MG/KG (≤ age 35)

0.006 - 0.125 MG/KG (≥ age 35)

7 Doses/Week

10 mg vial @ $605 or $765 /month

Eg 70kg = 0.42 x 30 days = 12.6 MG/Month

or * 70 X 0.025 = 1.75 X 30 DAYS = 52.5 MG/Month


A 63-year old female presents to the office with

the complaint of difficulty getting out of a

chair. She also has vague symptoms such as

fatigue and lack of energy in association with

morning stiffness and aching in the proximal

portions of her arms and legs. Lab data reveals

a mild anemia, normal biochemistry profile, and

a Westergren sedimentation rate of 75 mm/hr.

PE is unremarkable.



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CLINICAL FEATURES OF PMR

[SYMPTOMS AND SIGNS]

Pain

Stiffness

Fatigue

Depression

Disability

Tenderness

Limitation of Motion

- areas involved

Arthritis

Carpal Tunnel Syndrome


DEFINITION OF PMR

1. Pain in neck, shoulders, and pelvic girdle for

at least one month. Morning stiffness and

gelling without muscle atrophy or weakness.

2. Age ≥ 50 years old

3. ESR ≥ 50 mm/hr

4. Relief of symptoms within 4 days with as low

as 10-15 mg Prednisone per day.


DIFFERENTIAL DIAGNOSIS

OF PMR_____________________________________________________________________________

RA and other CTD

Viral Myalgias

Polymyositis

Multiple Myeloma

Osteoarthritis

Fibromyalgia

Occult CA

Occult Infection

Endocrine Disturbance


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LAB IN PMR

Anemia

ESR ( ≥ 50 MM/HR)

RA (-)

ANA (-)

Muscle Enzymes – Normal

EMG – Normal

Liver Profile


PMR - THERAPY

A) NSAIDS – trial warranted?

- will not prevent vascular

complications

B) Corticosteroids - *Drug of choice (low dose)

If Sx free x 6-12 months, may D/C steroids

50% may relapse

? Add MTX (steroid sparing)

conflicting reports

Prognosis

? Assoc. with ↑ CV mortality


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MANAGEMENT OF PMR

ASA or NSAID’s

Corticosteroids

- Dosage

- Duration

Biopsy

- Indications

Education

** N.B. 1 – Sudden Blindness 7 years After Dx.

N.B. 2 - PMR May Evolve into RA


CONTRASTS BETWEEN FM AND PMR

FM PMR

AGE

STIFFNESS

POOR SLEEP

TENDER PTS.

CONSTITUTIONAL

SYMPTOMS

ESR

30-45

+ -

+++

+++

(-)

NL

>50

+++

+ -

+ -

++

↑↑


CONTRAST IN THERAPY FM VS PMR

NSAIDS

EXERCISE

TCA’S

STEROIDS

MTX

FM

+

+

++

CI

CI

PMR

-

+-

+-

+++

++


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RELATION OF POLYMYALGIA RHEUMATICA

TO TEMPORAL ARTERITIS

Polymyalgia Rheumatica

Biopsy

Pos.

Symptomatic

Temporal

Arteritis

(Biopsy

Positive)


SYMPTOMS SUGGESTIVE OF

TEMPORAL ARTHERITIS (GCA)

Temporal Cephalgia

Diplopia

Amaurosis Fugax

Scalp Tenderness

Jaw Claudication


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DIAGNOSIS OF GCA

Clinical Suspicion

Biopsy of Temporal Artery

- Pathology

- Skip Lesions

- One or Both?

- Negative Biopsy?



GCA - THERAPY

Corticosteroids 0.7 – 1.0mg/kg/day

- maintain x one month before tapering

* Addition of 81mg ASA

May prevent occlusive disease

* Add Imuran /CTX / MTX

Steroid sparing

* Tocilizumab (Actemra) IV or SubQ


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