 Fibromyalgia  Burden of disease and disability. and h by drdoc on-line |
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William
Seward was the man who ultimately purchased
Alaska for the USA from Russia.
In fact,
Seward had been Lincoln’s greatest rival for presidential
nomination years before.
William Seward was married to a lady named Francis
Adeline Seward.
Francis was troubled by a mystery illness.
“Burdened with a fragile constitution, Francis was increasingly debilitated by a wide range of nervous disorders – nausea, temporary blindness, insomnia, migraines, mysterious pains in her muscles and joints, crying spells and sustained bouts of depression…A flashing light, a bumpy carriage ride or a piercing sound was often sufficient to send her to bed”…. “Doctors could not pinpoint the physical origin of the various ailments that conspired to leave Francis a semi-invalid"
 Perhaps,
if it had not been for the illness of Francis Adeleine Seward, who was
Seward's greatest inspiration and advisor, Abraham Lincoln may never have
reached the Presidency. Seward was his main rival in the elections that
led to Abraham Lincoln ultimately securing the Republican Party vote.
However, potentially diverted and with illness plaguing his wife, Seward potentially
lost his opportunity for his greatest ambition – to become President of
the United States and thereby, the mystery disease changed the history of
America.
Therefore history may well
have changed because of this strange and unusual condition If we analyze the actual symptoms suffered by Francis Seward, the mystery illness is almost certainly revealed as classical fibromyalgia.
Fibromyalgia is a condition that has fought for some years to attain
recognition as a specific entity.
The main complaint is of pain and discomfort
especially in the neck and shoulder girdle and low back and
they suffer from significant morning
stiffness and are beset by ongoing fatigue, insomnia, a ongoing
"brain
fog",
memory impairment and to complicate matters, suffer from widespread
somatic symptoms that include headaches, irritable bowel, irritable
bladder, jaw pain and become quite significantly dysfunctional.
The problem is that, other than the finding, on examination, of tender points, all tests are non-specific, and there is nothing that further characterizes the problem on the examination. This is in stark contrast to inflammatory arthritis, such as rheumatoid arthritis, where the presence of swelling and the clinical finding of an inflammatory joint arthropathy define the problem. In such inflammatory arthritis cases, tests may reflect inflammation and also the presence of antibodies. In fibromyalgia, all tests and investigations are NORMAL.
Because fibromyalgia reveals little on the examination, as a consequence, there
are many misconceptions that arise.
Patients have been dismissed as depressed or anxious, and simply as having a
failure to cope in society.
There is a misconception that the diagnosis requires the exclusion of all other
possibilities and in the past it was simply not recognized as a specific
condition. This has resulted in numerous dissertations, such as the eloquent Nortin Hadler who has published widely on the subject.
Papers such as:
In such eloquent papers, discussion in broad terms transmit the
opinion that
fibromyalgia constitutes a syndrome which is largely a diagnosis “of want of
another name.”
George Erlich widely recognized Professor of medicine at the University of
Pennsylvania, wrote similar articles.
“Pain is real; fibromyalgia isn’t”.
In an article he wrote “I am suggesting that chronic persistent pain is an
ideation a somatization if you will” …..
“I am further suggesting that these people choose to be patients because they
have exhausted there where withal to cope.”
But as has been seen in the South African experience, denial of disease even as radical as the denial of the presence of HIV – AIDS has been a lesson for us.
Our own former President,Thabo Mbeki and his
now late
Minister of Health Manto Tshabalala Mnsimang, for years verbalized their belief
that vegetables - lemons, african
potato, garlick, and lemons and diet alone, could
cure the “non existent disease” called AIDS. However, we all know that the
presence of the virus has been fully defined as the cause.
Similarly, in fibromyalgia now, we now know that in reality, the
syndrome is a neurological pain disorder, characterized by central
nervous system dysfunction with central sensitization of the actual
input of nerve transmission to the brain.
We know that neural origin pain is perhaps the most severe pain that patients
can suffer.
These patients are non-responsive to standard
anti-inflammatory drugs
or analgesics, and they search from healthcare provider to health provider
undertaking unnecessary tests, investigations, procedures and even surgery for
no good cause.
This amounts to enormous medical costs and little wonder that stress or
depression can be associated with the condition. These factors can further
contribute to the downward spiral and may well bring the condition to a head.
The diagnosis is a specific diagnosis. It is not a diagnosis of exclusion.
Symptoms of fibromyalgia include:
The American College of Rheumatology defined criteria for this problem in 1990.
The problem termed “criteria for fibromyalgia” included:
A history of widespread pain for more than three months on both sides of the
body – above and below the waist and axial skeleton (cervical spine, anterior
chest, thoracic pain or low back pain).
Association with the presence of 11 out of 18 tender points on physical
examination.
Of note the presence of second clinical disorder does not exclude the diagnosis
of fibromyalgia.
The tender points are located as follows:
Lower cervical – C5/6/7.
The
second costochondral junction.
The lateral epicondyle.
Supraspinatus. Occiput
Trapezius.
Gluteal.
Trochanteric bursa.
The medial knee.
This gave a sensitivity of 88.4% and a specificity of 81.1%. However, the ACR criteria where never intended to be applied to individual patients for the purpose of diagnosis.
Their use has been misinterpreted. They
are in fact, really for research purposes.
The diagnosis is a clinical one.
It is made on listening to the patient, plus clinical examination of the
patient.
A good examination will help to exclude other obvious underlying disease, such
as inflammatory arthritis, and thereafter one can do with a minimal amount of
tests, required to exclude perhaps, thyroid abnormalities, inflammation with an
ESR and CRP and blood count, and as few further radiological investigations as
possible.
As US Supreme Court justice, Potter Steward was often misquoted in the supreme
court of America in 1964 regarding the description of pornography: “I shall not
attempt to define the kind of material to be embraced within that description –
and perhaps I could never succeed in intelligibly doing so, but I know it when I
see it.”
Most rheumatologists would suggest that the diagnosis is easy to make.
The patients are easily recognized if one is aware, educated, and looks out for
it.
Yet this is a diagnosis that is usually missed by most primary practitioners and
many specialist physicians. In numerous studies that have been undertaken, it is quite common to find a long delay in the making of this diagnosis. In a survey of 368 patients of arthritis to evaluate impact on daily life, rheumatoid arthritis patients had a mean of 2.01 years, before diagnosis was made, compared to fibromyalgia, which had a delay to diagnosis of 6.67 years. This is similar to experience widely noted around the world. Clearly, primary physicians require education to recognize the condition.
Fibromyalgia will constitute between 5 and 6% of all patients presenting to
general practice.
10 to 27% of patients seeing a Rheumatologist have fibromyalgia.
It is 6 to 7 times more common in females.
Genetic relationships are noted.
The average age of the patient is between 30 and 60 years.
In fact, it may well occur in childhood as well.
20 to 30% of patients, who have fibromyalgia, will have noted that the problem
may have been precipitated by trauma or surgical or emotional distress or a
catastrophic event.
Co-existent rheumatic disease is possible.
As many as 25% of patients with rheumatoid arthritis and 80% with Lupus and 50%
of Sjogrens syndrome have been shown in some studies to have fibromyalgia as
co-existent problems.
Etiology:
We would define pain as an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in terms of such
damage.
The pain may be affected or influenced by the situation where or when the pain
arises. Fear relating to the underlying issue, and emotion or depression or even
optimism of the underlying individual will have a major impact on pain
perception. Cultural factors therefore play a major role in how an individual
interprets pain.
Types of pain
There are different types of pain.
1.
Peripheral or nociceptive pain: relates to
mechanical damage in the tissue and is also known as somatic or even visceral
pain, where there has been a chemical, inflammatory or mechanical component.
These problems include diseases such as osteoarthritis or rheumatoid and are
usually responsive to anti-inflammatories or anti-inflammatory or analgesic
medication.
2.
Neuropathic pain occurs with
damage or entrapment of peripheral nerve. This results in sensitivity of the
nerve and ongoing firing of the nerve membrane. This causes a poor response to
anti-inflammatories or painkillers and would occur commonly in diseases such as
diabetes or shingles or post hepatic neuralgia or trigeminal neuralgia.
3.
Central or non nociceptive pain.
This is the
most severe kind of pain. This relates to the central disturbance in pain
processing itself and includes conditions such as fibromyalgia, irritable bowel,
tension headaches or chronic idiopathic low back pain. These patients have
ongoing pain that is non responsive to analgesia or anti-inflammatory drugs or
even opiates. Unfortunately, many patients are treated with such drugs and
develop dependency on such drugs with their inappropriate use. They do respond
however to central neuro-active compounds such as Tricyclic or
Norepinephrine-serotonin-reuptake inhibitors and anti-epileptic drugs such as
Pregabalin or Neurontin.
The pain pathway.
The pain neuronal pathway starts at the receptor at the periphery.
The pain signal travels to the spinal cord. In doing so it utilizes either the
fast fibres known as the A-delta fibres, which are myelinated or alternatively
the unmyelinated and slower C- fibres.
At the periphery, the pain receptors maybe triggered by a
local insult, resulting in chemical mediators
such as substance P, Potassium ions, Adenosine
triphosphate – ATP, histamine and Bradykinin, as well as prostaglandins and
Calcitonin gene related peptide.
The signal transmits through the nerve to the dorsal horn of the spinal cord
where synapses transmit the signal to the spinothalamic tracts, and up to the
brainstem.
At the dorsal nerve root ganglion, the A-delta – rapid fibres- trigger the AMPA
receptors, which are Trans membrane receptors for glutamate.
The slower C fibers have the potential to trigger both the AMPA and NMDA
receptors.
The NMDA receptors however are usually blocked by magnesium ions, which prevent
glutamate entering the post synaptic cell and prevent signaling.
It is only when there is constant stimulation with glutamate able to displace
the magnesium ions, allowing glutamate to enter the cell and trigger the next
neuron.
Several mediators moderate what ascends up the spinal cord and this is termed
the gate control mechanism.
Descending neurons from the brainstem-- descend down the spinal cord and at the
level of the synapse, in the dorsal horn release endogenous opiodes, serotonin,
noradrenaline and gamma amino butyric acid –GABA. These therefore prevent
signals ascending up the spinothalamic tracts.
Disruption of this descending inhibitory pathway results in chronic pain
syndromes.
Chronic pain is defined as pain for more than three months without any
biological value.
In a survey of chronic pain in Europe, it is noted that pain in the form of
chronic pain, affects approximately 2% of the population.
Of these:
20% had associated depression.
60% were less able or unable to work.
20% were unemployed because of the pain.
66% had visited there doctor between 2-9 times in the previous six months.
50% were using over the counter analgesia
66% were taking prescription medication.
Chronic pain is caused by
Sensitization
of the pain receptors, which
unmask silent pain receptors known as collateral sprouting, where the receptor
field widens from the original source at the membrane or skin surface.
Central
sensitization. Large scale release of
glutamate causes chronic stimulation removing the magnesium block and allowing
ongoing stimulation.
This is called windup.
Deficiency of
the inhibitory descending fibres from the brainstem.
Spreading of the receptor fields occurs therefore to different spinal levels and
the problem becomes diffuse and involves the body in general.
It is this mechanism that we now believe is the cause of
fibromyalgia.
The pain of fibromyalgia is severe, ongoing, generalized and chronic.
The patients describe unrelenting and non-responsive pain.
Evidence for central pain mechanism of fibromyalgia.
Central pain dysregulation.
Peripheral tissues in fibromyalgia are normal.
MRI or biopsy of these peripheral tissues including what is often interpreted by
the patients as nodular lesions under their skin at these tender points, are
entirely normal.
There is no difference in peripheral tissue pathology.
There is an abnormal response however to different stimuli.
There is a normal threshold for sensing normal stimuli but is a lower threshold
at which such stimuli becomes painful and therefore these patients feel low
level of stimulation to be a pain source.
Multiple trials have been done showing the lower threshold at which pressure
becomes painful in these patients.
Similarly, temperature also may be recorded as painful at a lower temperature,
compared to that felt by normal subjects.
Fibromyalgia is thought to be disordered, sensory processing.
There is a reduction in inhibitory pathways and uncontrolled input of signals to
the brain – windup.
There is an uncontrolled spreading and intractable pain.
The smallest stimulation provokes pain – something called allodynia.
Functional MRI.
These studies demonstrate blood flow in the brain to
different stimuli.
Such changes may be recorded within seconds.
An elegant study, by Gracely et al, showed that a low stimulus of pressure
produced a high pain level and there was early triggering of cerebral blood flow
compared to triggering of control subjects who required greater pressure to
achieve the same pain levels and equivalent cerebral blood flow patterns.
Similar pressure resulted in low levels of pain.
Greater pressure was required to induce cerebral blood flow changes and the
perception of pain in normal subjects.
Studies showed that with pain from pressure applied to the thumb nail bed, that
there were 13 regions of increased brain activity revealed in a fibromyalgia
group, compared with 1 in the controlled group.
However, no statistical difference was identified when increased pressure
applied to controls, caused the same amount of pain sensation in the control
population compared to the subjective pain response of the fibromyalgia
patients.
SPECT and PET
scanning also demonstrate brain cerebral blood flow and brain
activity but are more delayed, compared to functional MRI. Therefore, the
functional MRI has provided the most accurate method to-date, of observing
cerebral blood flow in response to application of a stimulus.
Mountz and Bradley demonstrated a reduction in baseline thalamic metabolic
activity in fibromyalgia patients compared to normal control subjects.
NMDA receptor antagonists such as dextromethorphan and Ketamine reduce
experimental windup in fibromyalgia patients. Descending inhibitory pathways are
dysregulated in fibromyalgia patients as a response to noxious stimuli Spinal
fluid levels of 5 hydroxy-tryptamine, serotonin levels, are reduced. 5
hydroxy-tryptamine is a mediator in the inhibitory mechanism of the descending
inhibitory pathways.
Substance P, one of the mediators for stimulation of the dorsal horn neurons are
increased by almost 3 times, in the spinal cord of fibromyalgia patients.
We also note inflammatory cytokines are also increased, as is insulin like
growth factor.
Autonomic nervous system dysfunction.
The second mechanism which separates fibromyalgia from the average subject is
that of autonomic nervous system dysfunction. The autonomic nervous system
provides our fight – flight response.
It controls the nervous system that is “automatic”, that runs our bodies beyond
our control. This would include functions such as our heart rate, bowel,
urogenital and temperature homoeostatic responses to the environment.
The sympathetic nervous system persistently remains hyperactive in fibromyalgia
patients, and is hypo-reactive to stress.
There is an association between stress and enhanced pain.
In fibromyalgia patients, there is chronic hyper-stimulation of beta adrenergic
receptors, leading to receptor desensitization and down-regulation.
Therefore such patients are less able to respond to the surrounding stress or
homeostatic requirements to our surrounding environment.
Tilt - table testing has been shown to increase the incidence of orthostatic
hypotension compared to controls and there is a reduction in heart rate
variability on tilt table testing.
The autonomic nervous system supplies nerve supply to the visceral organs.
Dysregulation of this system, may well be the cause of the headaches and migraines that these
patients are noted to have.
In addition, it is associated also with the bladder problems, bowel problems,
temperature dysregulation, visual focus symptoms and oesophageal symptoms, as
well as the problems of fatigue, tiredness and “brain fog”.
It also aggravates the temperomandibular TMJ jaw syndrome.
Sleep dysfunction
Fibromyalgia patients frequently describe poor sleep pattern and feel unrested
on waking.
Abnormal sleep patterns on the electroencephalography EEG, with fibromyalgia,
were noted by Maldofsky years ago.
He demonstrated that patients deprived of stage four sleep developed
musculoskeletal symptoms and irritability.
Studies in fibromyalgia reveal an abnormality in the continuity of sleep and
sleep architecture.
Normal patients have a slow wave sleep pattern.
Fibromyalgia patients have alpha or alert wave intrusion in stage 4 REM sleep.
The consequence is increased wakening, non restorative sleep, daytime
somnolence, brain fog and irritability.
The genetics of fibromyalgia.
There is definite familial aggregation.
28% of children of fibromyalgia subjects will
develop fibromyalgia – this is equal to an 8.5 times risk of the problem. Similarly, family members revealed increased mood disorders and eating disorders as well as irritable bowel, back pain and migraine.
Genetics would appear to provide a predisposition
to developing the condition.
Role of psychiatry
There is increased psychiatric co morbidity.
Of patients with primary depression, more than 50%
will present with somatic symptoms.
Depression will worsen pain outcome, and vice versa.
Antidepressants normalize serotonin and adrenalin levels.
However, only 20% of fibromyalgia patients are
clinically significantly depressed, but up to 60% may have low levels of
depression.
20% of fibromyalgia patients had increased rates of anxiety. 7% will have panic
disorder and phobias will occur in 12% of patients.
Therefore, whilst depression and stress may be considered
part of the pattern, they are by no means the cause of the syndrome alone.
They certainly can influence the clinical picture
however.
In her dissertation on depression and fibromyalgia
in South Africa, Govender, showed 65% of patients had minimal to mild depression
and 35% had moderate to severe depression.
Secondary psychological factors.
And because of constant illness frequently without
diagnosis, patients fear the unknown.
Secondary stress and depression will occur in 33% of patients.
Patients endure unnecessary procedures and have difficulty
finding appropriate medical care.
They experienced huge health costs and are frequently
abandoned by healthcare providers.
The consequent loss of hope results in pessimism, and they become increasingly
labeled as psychiatric or psychologically disordered.
Epidemiology.
Studies in various communities around the world showed similar prevalence
between urban and rural communities as well as first world and Third World
communities.
The condition is not just a disease of the rich or avant-garde.
In
South Africa, a prevalence of fibromyalgia of 3.2% was noted in Cape rural
workers in a community in Bedford by Lyddell and Meyers.
(Scandinavia Journal of rheumatology 1992; supplement
94:8).
In New Zealand, fibromyalgia was noted in 1.1% of Maori population, compared to
Caucasians 1.5%.
In a study of 178 Amish adults in London, Ontario, the prevalence of
fibromyalgia amongst the Amish was 7.3% in the rural population, compared to
3.8% in the Amish urban population, and 1.2% of non-Amish rural dwellers.
The condition is six times more prevalent in females compared to males.
It can occur in children.
Financial cost of disease.
Financial costs are increased.
These include direct costs of health care, and indirect
costs affecting work or domestic life.
Penrod et al looked at health service costs in
women with fibromyalgia.
They noted visits to specialists and physicians
were increased.
Berger et al showed healthcare costs equal to $ 9573 compared to $ 3291 in and
fibromyalgia patients over a 12 month period. Health care costs were three times
higher with fibromyalgia patients compared to non-fibromyalgia patients.
Absence
from work was greater in fibromyalgia patients.
Fibromyalgia patients, on average were absent, 15.83 days
per year compared to 6.98 days of control population per year.
Fibromyalgia and disability.
Impairment is defined as the anatomical or physiological or psychological loss
leads to a disability.
Disability is a limitation of function that compromises an individual’s ability
to perform an activity of the range considered normal.
Work disability is the inability or diminished potential to engage in full-time
gainful employment.
Wolfe
et al looked at 1604 patients from six centers in the United States.
26% received at least one form of disability
payment.
16% received Social Security patients compared to
2.2% of the US population and 28.9% of patients with rheumatoid arthritis. The
steady illustrated that fibromyalgia was as disabling, as an inflammatory
arthritis such as rheumatoid arthritis.64% were still able to work.
Burkhardt et al showed that quality of life, in fact was lower in fibromyalgia
patients than in patients with rheumatoid arthritis or osteoarthritis.
This was despite the absence of physical damage.
Clearly, the Health insurance industry has taken issue with the diagnosis and
payment of healthcare benefits as well as disability benefits, to fibromyalgia
patients.
In a
survey of 1363 patients with fibromyalgia by the American pain foundation, 48%
had difficulty with coverage for fibromyalgia pain treatment.
15% had problems with copayment, 12% had problems
with premium affordability, 11% had delay in pre-authorization processes, 11%
had delay in access to FDA approved medication, 8% had repeated denial of
covered benefits.
Lobby
groups have fought this persistent discrimination against fibromyalgia patients.
Lynne Matallana, president and founder of the
non-profit National Fibromyalgia Association, wrote in the Pittsburgh
Post-Gazette, July 13, 2008, “There have been some insurers who take the stand
that if they make it more and more difficult for patients to get new treatments,
they will go away.”
In
South Africa, there has been a slow recognition of the existence and potential
for true disability amongst fibromyalgia patients. The illness is now listed in
most insurance company confidential medical report resumes to doctors.
Liberty life, one of the largest insurance
companies in South Africa, paid R 257 million in total disability payments in
2008.
Of these 18% went to trauma, 18% to cancer,
arthritis 4%, cardiac 7%, and skeletal 14%.
Association with trauma.
There
is a strong association between neck injury and fibromyalgia.
Buskila reported a 10 times increased risk.
There was a strong association with post traumatic
stress syndrome, and such patients with secondary fibromyalgia had a worse
outcome.
Disability compensation -up to 30% and loss of
employment up to 70%.
21% of
adults, developed fibromyalgia within one year of neck injuries from motor
vehicle accident.
Neck injuries resulted in greater risk, compared to
only the 2% of adults who developed fibromyalgia after lower limb extremity
fracture.
Of note, that there was no association between work
disability and medicolegal or insurance claims.
Individual cases have been settled by the Road accident fund in South Africa.
No specific policy has been finalized to assess all
patients with post-traumatic fibromyalgia.
There
is an ongoing controversy with the diagnosis and difficulty regarding perception
of secondary gain and secondary incentive...
Because of the minimal signs of examination and lack of
radiological damage, there is a bias against the patients with the disease and a
bias of the assessment of such patients.
Patients are referred for multiple opinions by the
industry until a contradictory position favoring the insurance company is found.
Moldofsky et al suggested in their paper, that the
studies did not show resolution of fibromyalgia at the conclusion of medicolegal
issues.
Nortin
Hadler’s assertion
that “if you have to prove you are ill, you can’t get well: the object lesson of
fibromyalgia “– is not shown to be really correct..
The
insurance panel requires appropriate physician selection.
The assessment should be thorough and timely and should be
perceived as fear.
The assessor should be independent without conflict
of interest. In fact there should be a registry of independent evaluators, who
are educated and ask appropriate questions and can examine appropriately without
bias.
Any
questionnaire used should be uniform.
For a proper assessment of function, one can use several
measurements.
The fibromyalgia impact questionnaire is a sensitive index of change and
correlates with the degree of disability.
The
average fibromyalgia patient equals 50 and severe is greater than 70.
The maximal score is 100.
The questionnaire includes 10 questions that reflect on function severity of
pain, fatigue, well-being, stiffness, anxiety, and depression.
The health assessment questionnaire looks at activity of daily life and includes
questions on dressing and grooming, arising, eating, well-being,
The SF36 questionnaire: looks at physical limitation, social limitation, daily
limitation, body pain, general mental health, vitality and general health
perception.
The
object of the patient – physician intervention is primarily to make a diagnosis
and to educate the patient regarding disease and contributing factors.
The physician must be optimistic and sympathetic
and encouraging but I’m biased.
Exercise must be encouraged.
Unnecessary procedures, investigations, and in
particular surgery must be avoided.
Painkillers, anti-inflammatory drugs, and sleeping polls must be avoided.
The
patient should be discouraged from actively seeking multiple opinions.
Explanation of the condition should provide the
definitive answer to the multiple complaints that have baffled the patient and
healthcare providers for so long prior to diagnosis.
It is very important for the patient to understand that
the entire multiple listings of complaints, are all from one single diagnosis –
fully explainable – fibromyalgia.
It is
interesting that the diagnosis is in fact an essential component of successful
fibromyalgia management.
Goldenberg et al and Fred Wolfe have shown that patient
satisfaction improves significantly after diagnosis.
In
addition,
Hughes et al showed that there is a
clear decrease in the visits to physicians, specialists and natural
practitioners as well as a decrease in diagnostic testing and procedures after
the diagnosis is made.
Therapy of fibromyalgia.
Non Pharmacological therapy
The most important non pharmacological therapy is exercise.
This
involves aerobic – cardiovascular exercise.
This is shown to be far more useful compared to strength
training or isometric exercises.
There is some evidence for hydrotherapy and hypnotherapy
and weak evidence for acupuncture and chiropractic and massage as well as
ultrasound therapy, but no evidence for flexibility exercises.
Pharmacological therapy.
There
is no evidence that opioid drugs, corticosteroids, nonsteroidal
anti-inflammatory drugs and painkillers, sedatives and benzodiazepines do any
help.
The only analgesic has modest evidence is that of
tramadol.
This is available in slow release 150mg, or short
acting 50 - 100 mg preparations, or even combination therapy with paracetomol as
Tramacet.
It is
important for the patient not to overuse anti pain – analgesic –medication.
Even morphine will not help the patient, who will
land up addicted and dependent to such narcotic medication that will serve no
purpose.
However, the greatest evidence is that of the old fashioned Tricyclic
antidepressants in low dose, including amitriptyline—Trepiline / tryptanol,
starting at 10 mg and possibly increasing to 25 mg.
This is taken, half an hour before bedtime at night. Side
effects include dizziness, excessive drowsiness, dry mouth and altered sleep
pattern – including an increase in dreams.
I always recommend to the patient, that they will
experience side-effects for the first few days, but that they must persist
despite these side-effects, in order to tolerate the drug.
Once on the drug, used must be regular rather than
an intermittent or “as required use.” These drugs work, by increasing descending
spinal inhibition pathways. Mild weight gain can occur.
This is dose dependent.
75% of patients will respond to Tricyclic antidepressants.
Some of the serotonin-noradrenaline reuptake inhibitors SNRI’S, such as
Milnacipran - Savella and Duloxetine – Cymbalta are also indicated, and now
registered, for fibromyalgia in America.
Duloxetine
has been studied in several trials, which show clear benefit above placebo.
Milnacipran has also been
studied and published showing a 60% reduction in pain intensity. Patient global
scores are also markedly improved, by 70 to 80%.
Selective Serotonin reuptake inhibitors SSRI’S such as venlafaxine – Efexor and
Fluoxetine – Prozac have a lesser role, as co therapy with amitriptyline. These
drugs are not as good as mixed serotonin and norepinephrine reuptake inhibitors
The selective serotonin reuptake inhibitors have side effects of somnolence,
dizziness, insomnia, constipation, dry mouth and loss of libido.
New anticonvulsants including Pregabalin -- Lyrica and Gabapentin – Neurontin
are also now registered for therapy of fibromyalgia.
Pregabalin blocks the neurotransmission of nerve signals in pain fibres, by
blocking calcium transport across the membrane. Calcium is required to
depolarize the membrane and allow release of neurotransmitter such as glutamate,
substance P. and norepinephrine. Pregabalin binds to the alpha 2-delta, subunits
of the voltage gated calcium channel in the central nervous system. This
prevents release of neurotransmitter to the post-synaptic membrane.
Therefore the signal does not progress to the next neuron.
This attenuates the pain pathway.
Pregabalin
is associated with an improvement in function as measured in the fibromyalgia
impact questionnaire scores at doses of 450 two 600 mg per day.
Patient
global improvements were between 60 and 80% at 150 -- 450 mg per day doses.
This was published by
Crofford et al in 2005.
Pregabalin has significant side-effects.
This includes dizziness, in one third of patients,
somnolence 20%, and weight gain in 7%...
Rash is described. Aggravation of depression is
also described.
In my experience weight gain is a potential problem and is aggravated by the
addition of amitriptyline
Other drugs:
There is very poor evidence for growth hormone and 5-hydroxytryptamine in
therapy.
There
is also no evidence for the innumerable number of natural therapies that are
claimed as miracle cures by the preying vultures and snake oil salesmen.
I term this “the walletectomy” – the surgical or
nonsurgical removal of the wallets of the fibromyalgia patients seeking miracle
cures to their symptoms that plague their lives.
Benzodiazepines such valium, Ativan, and other sedatives such as alprazolam –
Aropax, and Ambien – Stilnox, do not help and cause drowsiness,
light-headedness, depression, dry mouth and constipation.
Beta-blockers – non-selective-- such as propranolol,
Inderal/Purbloka, when given, in low dose, have a role to play as inhibitors of
the autonomic nervous system pathways.
These reduce headache/migraine and bowel symptoms.
I personally find them extremely useful for these
autonomic nervous system symptoms and also find them useful to calm the patient
without sedatives, which do not work anyway.
In summary
Fibromyalgia remains the most difficult problem to treat in rheumatology.
Patients suffer and are neglected and treated badly,
by
family, the medical profession and the insurance industry and health insurance
industry.
They are preyed on by snake oil salesmen – medical
and non-medical alike. They are the victim of excessive procedures and
investigations and surgical procedures, which are damaging and aggravated the
underlying cause.
They suffer.
They are labeled as neurotics and psychological.
The ignorant, including some medical practitioners and a
minority of rheumatologists, even deny the existence of the diagnosis.
The Copenhagen declaration in 1990, declared fibromyalgia to be a legitimate
diagnosis and granted the diagnosis a specific ICD10 – code – International
classification of disease – M.79.0.
Patients require expertise.
They require reassurance.
They deserve help.
They need to understand that their help will not be miraculous. However,
understanding the pathology, and the pathogenesis will provide major benefit to
the extent of the disease.
The practitioner needs to understand that patience is required. Failure to help the patient does not reflect a failure of the practitioner. It simply means that the disease is resilient. This will prevent patient movement from practitioner to practitioner, understanding that the practitioner is simply trying to do the best to help the individual patient concerned.
The problem is the disease and
not a deficiency of either the patient or the
practitioner.
David Gotlieb
References
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 The
big question- Does Barak Obama owe it all to Fibromyalgia ? |
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