Fibromyalgia Vs Polymyalgia Rideumatica

Home , Muscle atrophy

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

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.

#POMA19 #ChooseKnowledge

CLINICAL CLASSIFICATION OF THE RHEUMATIC DISEASES 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 #POMA19 Osteomalacia#ChooseKnowledge Hyperpara 3

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

NON-ARTICULAR RHEUMATISM

Fibromyalgia (Fibrositis) Reflex Dystrophies

Bursitis/Tendinitis Referred Pain

Tenosynovitis Nerve Entrapment

Viral Myalgia Pyschogenic Rheumatism

Hematoma (Muscular) Phlebitis

Panniculitis #POMA19 #ChooseKnowledge 4

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.

#POMA19 #ChooseKnowledge

Fibrositis Myositis Myofascial pain syndrome Myofasciitis

PRIMARY FIBROMYALGIA SYNDROME

• No Inflammation • Consistent symptom spectrum • No underlying cause

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

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.

#POMA19 #ChooseKnowledge

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 #POMA19 #ChooseKnowledge

PFS: MODULATING FACTORS

AGGRAVATING FACTORS RELIEVING FACTORS

Cold or humid weather Warm/dry weather Non-restorative sleep Hot shower/bath Physical/mental fatigue Restful sleep Excess physical activity Moderate activity Physical inactivity Stretching exercises Anxiety/stress Massage

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

PFS: EXAMINATION

POSITIVE NEGATIVE

Multiple Tender Muscle weakness Points Mild soft tissue Neurologic examination swelling (fingers) Skin pinch Joint examination Tenderness Hyperemia of skin

#POMA19 #ChooseKnowledge

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 #POMA19 #ChooseKnowledge

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

#POMA19 #ChooseKnowledge

⚫ 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

#POMA19 #ChooseKnowledge

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)

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

DIFFERENTIAL DX. of FIBROMYALGIA

1) PSYCHOGENIC RHEUMATISM 2) RA OR OTHER CTD 3) PALINDROMIC RHEUMATISM 4) OSTEOARTHRITIS 5) POLYMYALGIA RHEUMATICA 6) HYPOTHYROIDISM

#POMA19 #ChooseKnowledge

LABORATORY DATA (FIBROMYALGIA)

1) CBC 2) SED. RATE (ESR) 3) CMP 4) SEROLOGIES 5) EEG, EMG 6) BIOPSY

#POMA19 #ChooseKnowledge

ETIOLOGY (FIBROMYALGIA)

1) SLEEP DISTURBANCE a) Non-REM b) Alpha Intrusion 2) ?METABOLIC DERANGEMENT a) Serotonin (Brain) b) Tryptophan 3) ANXIETY AND/OR DEPPRESSION

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

#POMA19 #ChooseKnowledge

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. #POMA19 #ChooseKnowledge

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

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

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)

#POMA19 #ChooseKnowledge

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

#POMA19 #ChooseKnowledge

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

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

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

#POMA19 #ChooseKnowledge

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.

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

CLINICAL FEATURES OF PMR [SYMPTOMS AND SIGNS]

Pain Disability

Stiffness Tenderness

Fatigue Limitation of Motion - areas involved

Depression Arthritis Carpal Tunnel Syndrome #POMA19 #ChooseKnowledge

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.

#POMA19 #ChooseKnowledge

DIFFERENTIAL DIAGNOSIS OF PMR ______

RA and other CTD Osteoarthritis

Viral Myalgias Fibromyalgia

Polymyositis Occult CA

Multiple Myeloma Occult Infection

Endocrine Disturbance

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

#POMA19 #ChooseKnowledge

LAB IN PMR

Anemia ESR ( ≥ 50 MM/HR) RA (-) ANA (-) Muscle Enzymes – Normal EMG – Normal Liver Profile

#POMA19 #ChooseKnowledge

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

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

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

#POMA19 #ChooseKnowledge

CONTRASTS BETWEEN FM AND PMR

FM PMR

AGE 30-45 >50 STIFFNESS + - +++ POOR SLEEP +++ + - TENDER PTS. +++ + - CONSTITUTIONAL ++ SYMPTOMS (-) ↑↑ ESR NL

#POMA19 #ChooseKnowledge

CONTRAST IN THERAPY FM VS PMR

FM PMR

NSAIDS + -

EXERCISE + +-

TCA’S ++ +-

STEROIDS CI +++

MTX CI ++ #POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

#POMA19 #ChooseKnowledge

RELATION OF POLYMYALGIA RHEUMATICA TO TEMPORAL ARTERITIS

Polymyalgia Rheumatica Symptomatic Temporal Arteritis Biopsy (Biopsy Pos. Positive)

#POMA19 #ChooseKnowledge

SYMPTOMS SUGGESTIVE OF TEMPORAL ARTHERITIS (GCA)

Temporal Cephalgia Diplopia Amaurosis Fugax Scalp Tenderness Jaw Claudication

#POMA19 #ChooseKnowledge

POMA 111th Annual Clinical Assembly & Scientific Seminar May 1-4, 2019 “Fibromyalgia vs. Polymyalgia” Richard A. Pascucci, DO

DIAGNOSIS OF GCA

Clinical Suspicion

Biopsy of Temporal Artery

- Pathology - Skip Lesions - One or Both? - Negative Biopsy?

#POMA19 #ChooseKnowledge

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 #POMA19 #ChooseKnowledge

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