Fibromyalgia often exists with SLE

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Clare in Tassie

Fibromyalgia

Alan Lash, MD

Rheumatologist, Kaiser Hospital, Redwood City, CA

Preface

Fibromyalgia, which is described in detail in this article, frequently coexists with systemic lupus erythematosus (SLE). Among patients with SLE who experience widespread pain not readily explicable on the basis of arthritis or myositis, a diagnosis of fibromyalgia should be considered. Such patients often will respond poorly to anti-inflammatory therapy. On the other hand, fibromyalgia is not an autoimmune disease, and the vast majority of sufferers do not have, nor will they develop, SLE. Unfortunately, since fibromyalgia patients may occasionally test positive for antinuclear antibodies (ANA), usually at a low level, they may be incorrectly diagnosed as having lupus.

Introduction

Fibromyalgia (FM) is an illness characterized by longstanding widespread pain. It affects about 2% of the adult population. Women are affected much more commonly than men. Age of onset is usually the early thirties. Since it is a chronic illness, the prevalence of this disease increases with age such that it affects over 7% of women and 1% of men in their 60’s and 70’s. Other common symptoms include a perception of joint swelling, tingling of the extremities, stiffness in the morning, non-refreshing sleep, fatigue, headaches, abdominal pain associated the diarrhea or constipation, cold induced color change of the fingers, and dryness of the mouth or eyes.

The American College of Rheumatology’s criteria for the classification of fibromyalgia (published in 1990) includes a history of widespread pain (on both sides of the midline and of the waist and involving the spine or chest) present at least 3 months, plus the demonstration of at least 11 (out of a possible 18) tender points. Tender points are areas that are painful in patients with FM (but not in control subjects) when pressed with a certain degree of force. The presence of other disorders (e.g., arthritis) does not exclude the presence of FM.

For practical purposes, it is not necessary to have 11 tender points to diagnose FM. Patients with fewer than 11 tender points do not differ in any important way from those who meet classification criteria. Laboratory tests are also not necessary to make the diagnosis, but they are often obtained depending on the clinical situation and the judgement of the physician.

What Causes Fibromyalgia?

Fibromyalgia can be initially triggered by various stresses, including emotional, traumatic and illness experiences. Individuals who sustained neck injuries in motor vehicle accidents, for example, have been shown to develop FM at 13 times the incidence of those who had only lower extremity injuries. FM is probably due to abnormal processing of sensory signals in the nervous system. Pain signals appear to be amplified at the level of the spinal cord and may be processed abnormally in certain areas deep within the brain. As a result, non-noxious stimuli are perceived as being painful (such as pressure at tender points).

Among the most interesting evidence for pain amplification is that levels of substance P which transmits pain signals from peripheral receptors to the spinal cord, has been shown in a number of studies to be much higher (2 to 3 fold) in the spinal fluid of patients with FM than in healthy controls. One study showed an even higher level of substance P in the spinal fluid of FM patients who also had a brain abnormality called the Arnold-Chiari malformation. This may be due to blockage of flow of substance P from the spinal cord to the brain in these patients. Serotonin, a molecule made by nerve cells that is important in the regulation of pain, sleep and depression, inhibits the production of substance P. Low levels of serotonin in various sites have been demonstrated in patients with FM. Other abnormalities in the spinal fluid of FM patients have been identified as well, including high levels of nerve growth factor and low levels of norepinephrine. A preliminary study has suggested that blood flow to certain pain processing areas of the brain is low in FM. Abnormalities of certain hormones (especially cortisol and somatomedin C) have been described, but they are of uncertain significance. There is no convincing evidence that abnormalities of muscle, inflammation or immune function are important in FM. Sometimes sleep disturbance, depression and anxiety may aggravate (and be aggravated by) FM, but none of these conditions are likely to be a central or necessary part of the process of fibromyalgia.

What is the Natural History of Fibromyalgia?

Most studies suggest that FM is a chronic illness that does not change much over time. One study showed a more favorable outcome, perhaps reflecting the inclusion of less severely affected patients. One study found that, at 10-year follow-up, most patients continued to be fairly symptomatic, although most felt that they were doing better than they had done initially. In the United States, approximately 10% of FM patients are receiving disability benefits. Many others have filed for benefits, changed jobs or retired.

Treatment

It is extremely important for the health care provider to treat patients with FM with respect and empathy. (emphasis mine!) Certain cognitive-behavioral modalities have been studied, including aerobic exercise, education, biofeedback, meditation, cognitive restructuring and hypnotherapy, and they appear to have some benefit. The value of "passive" modalities, including ultrasound, massage and chiropractic, are not proven and are difficult to study for methodological reasons. Two passive modalities, injection of "trigger points" with an anesthetic and acupuncture, have shown possible efficacy. There have been encouraging reports of combinations of treatments. One uncontrolled study of an intensive six-month multidisciplinary program showed impressive improvement in many outcome measurements (and in terms of weekly pain-free intervals) which was sustained for at least 1½ years after completion.

Even though the most consistently effective medication is the tricyclic anti-depressant amitriptyline, the response rate is less than 30% and the therapeutic benefit often decreases after 2 to 3 months. Interrupting therapy for 2 to 4 weeks can circumvent this. Certain other drugs of this class (especially nortriptyline and imipramine) seem to be similarly effective with fewer side effects. Other drugs that have shown benefit in at least one trial include cyclobenzaprine, venlafaxine, tramadol, ondansetron and growth hormone. The dietary supplements s-adenosyl-L-methionine (SAM-e) and 5-hydroxytryptophan have also been effective in small trials. Drugs which have been studied and failed to show benefit include fluoxetine (although one study found synergy with it and amitriptyline), nonsteroidal anti-inflammatory drugs, prednisone and the dietary supplement malic acid. An unpublished study failed to show benefit of guiafenesin. The effect of benzodiazepine anti-anxiety drugs and of narcotics is unknown. One study found that, although most had tried narcotic medication, only a small percentage of FM patients felt it significantly improved their pain or quality of life. There are no data currently on the use of anticonvulsants, such as gabapentin, in fibromyalgia.

Summary

Fibromyalgia is a common chronic illness that is probably due to abnormal processing of pain signals in the nervous system. Although objective abnormalities have been demonstrated experimentally, the diagnosis is made by history and physical examination. No cure is yet available. Many patients can achieve improvement with treatment. It is likely that a multidisciplinary approach, incorporating both medication, cognitive-behavioral and, possibly, passive modalities, will offer the best results.

Reprinted from: NewSLEtter, a publication of the Lupus Foundation of Northern California

http://www.lupusmd.org/docs/body-fibromyalgia.html

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