Curbside Consult: Fibromyalgia

The 2009 American College of Rheumatology/Association of Rheumatology Health Professionals Scientific Meeting will feature several “Curbside Consult/Ask the Professors” sessions. Designed to feature information and discussion about “difficult management decisions that must be made in the absence of strong data,” these sessions give attendees the opportunity to “compare their personal management approaches” to the clinical problems outlined in the featured vignettes and scenarios with those of “the academic expert consultants and other clinicians in the audience.” The format calls for the presenter to outline a case study, with symptoms and other presenting characteristics, relevant medical and diagnostic history, and other key information, and then ask the attendees to select which course of treatment/next steps they would take from a pre-determined list of options. Selections are made using one of the handheld Audience Response Systems that are practically ubiquitous at medical conferences nowadays. After the votes are tallied, the results are displayed to the audience and the presenter follows up with a review of published evidence and clinical experience that could inform this hypothetical treatment decision. After this follow-up data is presented, the audience is asked to consider this information and vote a second time, to gauge the information’s impact on their clinical decision-making process.

This morning, as part of a session that also featured similar “consults” from other experts on scleroderma and systemic lupus erythematosus, Philip J. Mease, MD, from Seattle Rheumatology in Seattle, WA, briefly presented the case of a 34-year-old woman with a six-year history of CCP+ erosive RA and fibromyalgia whose RA is controlled with medications. She complains that she is tired all the time, with multiple areas of discomfort in neck, hip, and back. Among other information outlined in the case, the patients reports significant impairment of her quality of life, and says that she cannot differentiate between the symptoms of RA and fibromyalgia. A joint exam showed 10 tender points but no swollen points.

Audience members were asked what they would recommend next for this patient: increase amytryptiline to 25mg; prescribe prednisone; refer her for group physical therapy; prescribe a trial of pregabalin, duloxetine, or other SNRI; offer tender point injections; or some combination of these. The display of composite results showed that most audience members would go with a combination of medication and physical therapy. Following the vote, Mease briefly discussed current fibromyalgia diagnostic criteria, new studies using revised criteria (Wolf, et al. and their work using the widespread pain index, symptom severity score, etc). Mease also offered a slide that summarized results from several studies that have shown that fibromyalgia patients are more sensitive to painful stimulus than controls — researchers have used fMRI to reveal activity in the pain processing centers of the brain – demonstrating that there is less activity in fibromyalgia patients in areas of the brain related to pain sensitivity.

Mease also highlighted several studies that have shown an increased prevalence of fibromyalgia in patients with lupus, rheumatoid arthritis (17% concomitance), and Sjogren’s syndrome. He also noted that patients with fibromyalgia and rheumatoid arthritis have more symptom expression than patients with rheumatoid arthritis alone (as well as more reported disability). He reminded the audience to consider the impact of fibromyalgia on tender point count and patient global when making treatment decisions about immunomodulatory agents. The data is strongest, he said, for physical exercise, cognitive-behavioral therapy, patient education/self-management, and multi-disciplinary management with a medication component. There is some evidence supporting the effectiveness of tricyclics, SNRIs such as duloxetine, and alpha-2-delta modulators. The data for SNRIs shows they can help improve fatigue, patient global, and pain.

The second audience vote showed a slight shift in stronger favor of using a combination of exercise therapy/cognitive-behavioral therapy, and medication therapy with duloxetine, pregabalin, or others.