WASHINGTON — Two comprehensive presentations here at the American College of Rheumatology Annual Meeting sought to categorize the myriad of pain-related, functional and depressive disorders experienced by patients with fibromyalgia.
Daniel J. Clauw, MD, a rheumatologist and professor of anesthesiology and medicine and director of the Chronic Pain and Fatigue Research Center at the University of Michigan, focused on the nature of pain experienced by patients with fibromyalgia and how clinicians can treat it. Carmen E Gota, MD, of the Cleveland Clinic, stressed the importance of exercise and tailored patient care.
Nature of pain
Clauw discussed three categories of pain: peripheral pain; peripheral neuropathic pain; and centralized pain. “Fibromyalgia is the poster child for this third category of pain,” he said, but added there is disagreement about how to name and categorize that centralized pain. For Clauw, the issue becomes one of assessing the individual patient, rather than trying to categorize the disease state.
“You find evidence of peripheral pain, you treat that,” he said. “If you find evidence of neuropathic pain, you treat that. Then find the evidence of centralized pain and treat that.”
Some clinicians have used the term “fibromyalgia-ness” to describe the diversity of the disease.
“Instead of thinking of it as one disease, think about the factors that impact individual patients — sleep disorder, fatigue, various kinds of pain, depression, trouble concentrating,” he said. “It is also important to remember that fibromyalgia may be the tip of the iceberg. These symptoms may indicate something else.”
Clauw said many of the drugs used to treat fibromyalgia are limited. In particular, he warned about over-use of opioids.
“The body’s natural opioid production system may be impacted in fibromyalgia, so giving them opioids could be fueling the fire,” he said.
Clauw suggested that clinicians should pay attention to centralized pain. The strongest evidence shows tricyclic compounds, serotonin and norepinephrine reuptake inhibitors, and gabapentinoids have the strongest evidence for treatment of this type of pain.
“Overall, though, we need to use drugs in a more nuanced way,” he said.
Gota’s talk focused on non-pharmacologic interventions, particularly exercise. She stressed these interventions in light of increased prescription drug use among patients with fibromyalgia.
“In 2010, about 80% of patients were taking analgesic drugs and 52% were taking central acting drugs,” she said. “Over time, we have seen an increasing use of [central nervous system] CNS drugs. However, despite the increasing use of centrally acting drugs, we do not see a decrease in use of analgesics.”
Beyond exercise, other non-pharmacological interventions include cognitive behavioral therapies; multicomponent therapies; physical therapy, such as acupuncture or hydrotherapy; and mediation.
“In terms of the guidelines, the only one we had a strong recommendation for is exercise,” she said. “Exercise has been shown to have consistent impact on a number of domains.”
Like Clauw, Gota stressed individual patient management rather than trying to categorize the patient into a disease state. Identification of unmodifiable and modifiable factors is critical.
“It is important to know your patient, because that will determine how you are going to treat your patient,” she added. “Establish a network of collaborators who will help treat your patient, including primary care providers, physical therapists, psychologists or psychiatrists, and sleep medicine experts.” — by Rob Volansky
Clauw DJ and Gota CE. Fibromyalgia. Presented at: The American College of Rheumatology Annual Meeting; Nov. 11-16, 2016; Washington.
Disclosures: Clauw and Gota report no relevant financial disclosures.