Frequency of concomitant fibromyalgia in rheumatic diseases: Monocentric study of 691 patients

doi:10.1016/j.semarthrit.2017.01.005

Seminars in Arthritis and Rheumatism

Volume 47, Issue 1, August 2017, Pages 129-132

https://doi.org/10.1016/j.semarthrit.2017.01.005 Get rights and content

Abstract

Objective

Fibromyalgia (FM) is a confounding factor for diagnosing and assessing rheumatic disease activity. This study sought to assess the extent of this syndrome in rheumatism patients at a French rheumatology department.

Method

This monocentric epidemiological study enrolled all patients consulting due to rheumatoid arthritis (RA), spondyloarthritis (SpA), or connective tissue disease (CTD). FM diagnosis was confirmed or excluded according to the rheumatologist opinion and the 1990 American College of Rheumatology (ACR) criteria.

Results

We enrolled 691 patients, including 451 women (65.3%), with a mean age of 55.8 years (18–93). Of the enrolled patients, 325 presented with RA, 298 SpA [59 psoriatic arthritis (PsA), 137 ankylosing spondylitis (AS), 64 non-radiographic SpA (nr-SpA), and 38 peripheral SpA], and 71 CTD. The rheumatologist established FM diagnosis in 97 patients (14%), while 55 (8%) fulfilled the 1990 ACR criteria. The frequency of FM was lower in RA patients (4.9% by 1990 ACR criteria; 7.7% by expert opinion) compared to SpA (11.1% by 1990 ACR, p < 0.05; 17.5% by expert opinion, p < 0.003) and CTD (11.3% by 1990 ACR, non-significant; 28.2% by expert opinion, p < 0.001). In the SpA subgroups, FM was more common in the nr-SpA than in PsA or AS (23.9%, 9.6%, and 6.4%, by 1990 ACR, p = 0.001; 37.3%, 13.5%, and 7.2%, by expert opinion, p < 0.001).

Conclusion

FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in non-radiographic axial SpA, thus raising questions about the specificity of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria.

Introduction

Fibromyalgia (FM) is a syndrome combining cognitive disturbance, sleep disorders, fatigue, and associated chronic widespread pain. Its prevalence is 2% in the general population, higher in rheumatic disease cases, and considerably varying depending on the diagnostic criteria used [1], [2]. FM is diagnosed in 6.6–22.4% of patients with rheumatoid arthritis (RA) [3], [4], [5], with an incidence of 7%, maximal in the first year following RA diagnosis [6]. It has also been reported in association with ankylosing spondylitis (AS) (4–15% of patients) [7], [8], systemic lupus erythematosus (SLE) (6.2–24% of patients) [5], [9], [10], [11], and Sjögren’s syndrome (SS) (12–30%) [12], [13].

In clinical practice, FM is a confounding factor in rheumatic disease cases in terms of both diagnosis and disease activity assessment. Firstly, distinguishing FM from rheumatic disease can be challenging, particularly in non-radiographic axial spondyloarthritis (nr-axial SpA), due to the widespread, primarily axial pain, fatigue, and sleep disorders that are common clinical features of both conditions, as well as the enthesitis sites potentially overlapping with FM tender points. Secondly, concomitant FM disrupts disease activity and functional impairment assessment of RA and spondyloarthritis (SpA). It leads to overestimations in the 28-joint Disease Activity Score, as well as the BASFI and BASDAI indices, and causes non-justified therapeutic intensification [4], [5], [6], [14] with more frequent use of biological therapy [15].

Our study sought to compare frequency of concomitant FM in rheumatic diseases in a rheumatology department in routine practice.

Section snippets

Methods

The study was approved by the local ethics committee (Comité de Protection des Personnes Sud Est VI) (IRB: 00008526), and written consent was obtained from all patients who agreed to participate in the study, in accordance with the Declaration of Helsinki.

Patient characteristics

In total, 691 patients with a rheumatic disease were enrolled between September 2014 and April 2015. The total population consisted of 451 women (65.3%) and 240 men (35.7%), with a mean age of 55.8 ± 15.5 years (Table 1). The population included 325 RA cases, 298 SpA cases (categorized as 59 PsA, 137 AS, 64 nr-axial SpA, and 38 peripheral SpA), and 71 CTD cases (28 SLE, 27 SS, 14 Scl, and 6 myositis).

Frequency of concomitant fibromyalgia in the three inflammatory rheumatic disease groups

The frequency of concomitant FM varied according to the criteria used and the rheumatic disease

Discussion

In our study, 8–14% of rheumatic disease patients (primarily women) were affected with a concurrent FM. The rheumatologist diagnosed more FM cases than the 1990 ACR criteria. Concurrent FM was significantly less common in patients with RA than in those with SpA and CTD. This syndrome is much more common in nr-axial SpA than in AS or PsA.

FM is more common in rheumatic disease populations than in the general population, in which the prevalence does not exceed 2% in France [1], [2]. One possible

Conclusion

FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in nr-axial SpA and raises questions about the specificity of the ASAS classification criteria.

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Cited by (44)

Sjogren's syndrome, sicca asthenia and polyalgia syndrome (SAPS) and fibromyalgia
2022, Revue du Rhumatisme Monographies
L’association sécheresse des yeux et de la bouche, fatigue et douleurs des membres évoque un syndrome de Sjögren primaire (SSp), ou maladie de Sjögren, qui est une maladie auto-immune systémique. L’association caractérise aussi le syndrome asthénie polyalgie sécheresse (SAPS) qui est considéré comme un équivalent de fibromyalgie et elle est fréquente dans la fibromyalgie. Ces deux entités ont une forte prévalence contrairement au SSp. La distinction entre ces pathologies se fait par l’application des critères ACR/EULAR du SSp qui exigent la présence d’anticorps anti-SSA ou un focus score ≥ 1 sur la biopsie de glandes salivaires accessoires (BGSA). En l’absence d’anticorps anti-SSA et quand la probabilité diagnostique est faible, l’échographie des glandes salivaires qui a une forte valeur prédictive négative, pourrait être une étape intermédiaire avant de décider la BGSA qui est un peu plus agressive. Environ 20 % des patients atteints de SSp ont un syndrome fibromyalgique concomitant. Ces patients ont un score EULAR Sjögren's Syndrome Patient Related Index (ESSPRI) (évaluation par une EVA de douleur, fatigue et sécheresse) plus élevé, alors que le score EULAR Sjögren’ Syndrome Disease Activity Index (ESSDAI) qui mesure l’atteinte systémique, n’est pas différent des patients sans fibromyalgie. Dans cette population, contrairement à la fibromyalgie primitive, la concordance des critères de fibromyalgie n’est pas bonne. Les symptômes de la fibromyalgie et du SSp sont similaires et les critères de fibromyalgie ont des difficultés à les différencier.
The combination of dry eyes and mouth, fatigue and pain in the limbs suggests Sjögren's syndrome, a systemic autoimmune disease. The association also characterizes the sicca, asthenia, polyalgia syndrome (SAPS), which is considered to be an equivalent of fibromyalgia and is common in fibromyalgia. These 2 entities have a high prevalence unlike Sjögren's syndrome. The distinction between these pathologies is made by applying the ACR/EULAR criteria for Sjögren's syndrome which require the presence of anti-SSA or a focus score ≥ 1 on the labial salivary gland biopsy (LSGB). In the absence of anti-SSA and when the diagnostic probability is low, the salivary gland ultrasonography, which shows a high negative predictive value, could be an intermediate step before deciding on the LSGB, which is a little more aggressive. About 20% of patients with Sjogren's syndrome have concomitant fibromyalgia. These patients have a higher ESSPRI score (EULAR Sjögren's Syndrome Patient Related Index) (assessment by a VAS of pain, fatigue and dryness), while the ESSDAI score (EULAR Sjögren’ Syndrome Disease Activity Index) which measures systemic impairment, is no different from patients without fibromyalgia. In this population, unlike primary fibromyalgia, agreement between the fibromyalgia criteria is not good. The symptoms of fibromyalgia and Sjogren’ syndrome are very similar, and fibromyalgia criteria have difficulty discriminating between them.
Impact of the association of fibromyalgia and spondyloarthritis: A systematic review of the literature and meta-analysis of observational studies
2021, Revue du Rhumatisme (Edition Francaise)
L’objectif de ce travail était de rechercher la prévalence de la fibromyalgie (FM) dans les spondyloarthrites (SpA) et de mesurer l’impact d’une telle association sur les critères de suivi de la SpA. Aucune méta-analyse n’avait encore englobé ces différents éléments.
La recherche bibliographique a été réalisée sur les bases de données Pubmed, Embase, Cochrane library, les abstracts des congrès EULAR et ACR avec sélection des études observationnelles comparant les caractéristiques des patients ayant une SpA avec ou sans fibromyalgie. Les données ont été recueillies indépendamment par deux lecteurs.
Sur les 433 articles identifiés, 14 études remplissaient les critères d’inclusion pour un total de 4923 patients. La prévalence de la FM dans la SpA était de 18 % IC95 % [0,13 ; 0,23] avec un sexe ratio femme/homme de 5,13 IC95 %[3,02 ; 8,70] dans les SpA avec FM. La présence d’une FM associée majorait significativement les scores d’activité de la SpA : BASDAI : MD (Différence moyenne) = 2,29 IC95 %[1,57 ; 3,00] ; ASDAS-CRP : MD = 0,54 IC95 %[0,05 ; 1,02]. Elle a également un impact fonctionnel et sur la qualité de vie : BASFI : MD = 2,33 IC95 %[1,65 ; 3,02] ; AsQoL : MD = 5,50 IC95 %[4,28 ; 6,71]. Aucune différence statistique n’était retrouvée concernant le statut HLAB27, l’ancienneté de la maladie, la CRP et la prévalence d’anti-TNF.
Dans cette méta-analyse, la prévalence de la FM était de 18 %, contre 1,6 % dans la population générale. L’association d’une FM a un impact sur les scores d’activité de la SpA, un impact fonctionnel et sur la qualité de vie de la SpA.
Cannabis and cannabidiol (CBD) for the treatment of fibromyalgia
2020, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
Sleep disturbance is a cardinal symptom of fibromyalgia, with only 30% of fibromyalgia patients reporting “optimal sleep” in a large cross-sectional study of 3035 fibromyalgia patients [28]. The association between fibromyalgia and rheumatological diseases (e.g., rheumatoid arthritis (RA), systemic lupus erythematosus, ankylosing spondylitis, osteoarthritis, etc.) has also been well established [29–32]. A number of factors have been attributed to the development of fibromyalgia, including abnormalities in the neuroendocrine and autonomic nervous systems, genetic factors, psychosocial variables, and environmental stressors [33].
Fibromyalgia is a complex disease process that is as prevalent as it is poorly understood. Research into the pathophysiology is ongoing, and findings will likely assist in identifying new therapeutic options to augment those in existence today that are still insufficient for the care of a large population of patients. Recent evidence describes the use of cannabinoids in the treatment of fibromyalgia. This study provides a systematic, thorough review of the evidence alongside a review of the seminal data regarding the pathophysiology, diagnosis, and current treatment options. Fibromyalgia is characterized by widespread chronic pain, fatigue, and depressive episodes without an organic diagnosis, which may be prevalent in up to 10% of the population and carries a significant cost in healthcare utilization, morbidity, a reduced quality of life, and productivity. It is frequently associated with psychiatric comorbidities. The diagnosis is clinical and usually prolonged, and diagnostic criteria continue to evolve. Some therapies have been previously described, including neuropathic medications, milnacipran, and antidepressants. Despite some level of efficacy, only physical exercise has strong evidence to support it. Cannabis has been used historically to treat different pain conditions since ancient times. Recent advances allowed for the isolation of the active substances in cannabis and the production of cannabinoid products that are nearly devoid of psychoactive influence and provide pain relief and alleviation of other symptoms. Many of these, as well as cannabis itself, are approved for use in chronic pain conditions. Evidence supporting cannabis in chronic pain conditions is plentiful; however, in fibromyalgia, they are mostly limited. Only a handful of randomized trials exists, and their objectivity has been questioned. However, many retrospective trials and patient surveys suggest the significant alleviation of pain, improvement in sleep, and abatement of associated symptoms. Evidence supporting the use of cannabis in chronic pain and specifically in fibromyalgia is being gathered as the use of cannabis increases with current global trends. While the current evidence is still limited, emerging data do suggest a positive effect of cannabis in fibromyalgia. Cannabis use is not without risks, including psychiatric, cognitive, and developmental as well as the risks of addiction. As such, clinical judgment is warranted to weigh these risks and prescribe to patients who are more likely to benefit from this treatment. Further research is required to define appropriate patient selection and treatment regimens.
Comorbidities in psoriatic arthritis: How to manage them in clinical practice?
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La prise en charge du rhumatisme psoriasique est complexe du fait des manifestations articulaires hétérogènes, des manifestations cutanées et des comorbidités très fréquentes qui contribuent à l’altération de la qualité de vie et à l’augmentation de la morbi-mortalité. Les comorbidités cardiovasculaires et métaboliques sont au premier plan, représentées par les maladies cardiovasculaires, le syndrome métabolique, le diabète de type 2 et la stéatose hépatique non alcoolique. Au-delà des mécanismes inflammatoires bien connus dans le développement des maladies cardiovasculaires au cours des rhumatismes inflammatoires chroniques, le tissu adipeux et la production d’adipokines jouent un rôle déterminant. L’anxiété, la dépression, la fibromyalgie sont également des comorbidités majeures à prendre en compte. Le dépistage et la prise en charge d’autres comorbidités communes aux rhumatismes inflammatoires chroniques (cancers, infections) ont fait l’objet de recommandations et font désormais partie des bonnes pratiques alors que certaines comorbidités émergentes (syndrome d’apnée du sommeil, bronchite chronique obstructive, dysfonction sexuelle) n’ont fait pour l’instant l’objet que de peu d’études et nécessiteront une meilleure évaluation pour améliorer la prise en charge des patients. Le dépistage systématique et les recommandations des sociétés savantes sont nécessaires et utiles mais soulèvent la question de l’applicabilité en pratique et de l’inertie médicale. L’implication des infirmières d’éducation thérapeutique et le développement des infirmières en pratique avancée sont des enjeux importants pour améliorer la prévention et la gestion globale des patients atteints de maladie chronique.
Psoriatic arthritis is a heterogeneous disease including various rheumatologic and skin manifestations. Frequent comorbidities contribute to impaired quality of life and increased morbidity and mortality. Metabolic and cardiovascular comorbidities, represented by cardiovascular diseases, metabolic syndrome, type 2 diabetes and non-alcoholic fatty liver disease, account for a considerable burden. Beyond the role of inflammation in the development of cardiovascular diseases during chronic inflammatory rheumatic diseases, adipose tissue and the production of adipokines may play a critical role. Moreover, anxiety, depression, and fibromyalgia are also major comorbidities that need to be addressed. Recommendations for the management of comorbidities common to chronic inflammatory rheumatic diseases (cancers, infections) have been proposed and are now part of good practice. Fewer studies have addressed emerging comorbidities (sleep apnea syndrome, chronic obstructive bronchitis, sexual dysfunction) and they will require a better evaluation to improve the holistic management of patients. Systematic screenings and management recommendations have been found to be useful for patients but raise the question of implementation of recommendation and clinical inertia. The involvement of rheumatology nurses and the development of advanced practice nurses are important issues for improving prevention and overall management of patients with chronic diseases.
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View all citing articles on Scopus

: This research receives a funding Grant from the University Hospital of Clermont-Ferrand (Grant no. AOI DUBOST 2014).

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Frequency of concomitant fibromyalgia in rheumatic diseases: Monocentric study of 691 patients

Abstract

Objective

Method

Results

Conclusion

Introduction

Section snippets

Methods

Patient characteristics

Frequency of concomitant fibromyalgia in the three inflammatory rheumatic disease groups

Discussion

Conclusion

Fibromyalgia syndrome in the general population of France: a prevalence study

Joint Bone Spine

Prevalence of fibromyalgia in France: a multi-step study research combining national screening and clinical confirmation: the DEFI study (determination of Epidemiology of FIbromyalgia)

BMC Musculoskelet Disord

Fibromyalgic rheumatoid arthritis and disease assessment

Rheumatology (Oxford)

Disease activity score in rheumatoid arthritis with or without secondary fibromyalgia

J Coll Phys Surg Pak

Fibromyalgia in patients with other rheumatic diseases: prevalence and relationship with disease activity

Rheumatol Int

Incidence and predictors of secondary fibromyalgia in an early arthritis cohort

Ann Rheum Dis

Occurrence of fibromyalgia in patients with ankylosing spondylitis

Rev Bras Reumatol

Fibromyalgia in patients with ankylosing spondylitis: prevalence and utility of the measures of activity, function and radiological damage

Clin Exp Rheumatol

Neurally mediated hypotension in systemic lupus erythematosus patients with fibromyalgia

Rheumatology (Oxford)

Prevalence and factors associated with fibromyalgia in Mexican patients with systemic lupus erythematosus

Lupus

Fibromyalgia prevalence and related factors in a large registry of patients with systemic lupus erythematosus

Clin Exp Rheumatol

Fatigue in primary Sjögren’s syndrome: is there a link with the fibromyalgia syndrome?

Ann Rheum Dis