Rheumatology Potpourri: A Mixture of PMR, OA and FM. May 25, 2015

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1 Rheumatology Potpourri: A Mixture of PMR, OA and FM May 25, 2015 Kim Northcott MD, FRCPC, ABIM Rheumatology Consultant Division of Rheumatology VIHA South Victoria BC Clinical Instructor Division of Rheumatology University of British Columbia 1. Polymyalgia Rheumatica (PMR) REQUIRED CRITERIA: 50 years old Bilateral shoulder aching Abnormal CRP and/or ESR SCORING ALGORITHM: Points without US (0-6) Points with US (0-8) Morning stiffness duration >45 minutes 2 2 Hip pain or limited range of motion 1 1 Absence of RF or CCP Ab 2 2 Absence of other joint involvement 1 1 At least 1 shoulder with subdeltoid bursitis and/or biceps Not applicable 1 tenosynovitis and/or glenohumeral synovitis and at least 1 hip with synovitis and/or trochanteric bursitis Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis Not applicable 1 A score of 4 or more without ultrasound is categorized as PMR (sensitivity 68%, specificity 78%). A score of 5 or more with ultrasound is categorized as PMR (sensitivity 66%, specificity 81%). The need for imaging arises when there is diagnostic uncertainty. Response to corticosteroids is assumed to be a cardinal feature of PMR. There is little evidence to substantiate this. Reevaluating the risk score model for patient response to corticosteroids did not change the odds ratio. A steroid response is outlined as achieving at least 70% global improvement in one week and normal acute phase reactants in 3-4 weeks on prednisone 15-20mg.

2 Initial glucocorticoid doses of 20-30mg po qd have a lower relapse rate at 2 months than 10-20mg po qd as reported in 1 high quality level of evidence randomized controlled trial. It is strongly advised not to use >30mg of prednisone based on evidence of harm from long term high dose glucocorticoids and lack of future benefit of a high dose regimen. There is no consistent evidence for an ideal steroid tapering regimen suitable for all patients. Treatment must be flexible and tailored. Current guidelines recommend tapering by 10-20% q 2-4 weeks until 10 mg po qd is achieved ideally within 4-8 weeks and maintained 4-6 weeks. The taper is subsequently slowed by 1mg q4 weeks or by using an alternate day regimen (eg. 10mg 1 day alternating with 7.5mg every other day q4-8 weeks) until discontinued assuming remission is maintained. Usually 1-2 years of treatment is needed. Some patients require small doses of steroid beyond this. Disease flares are common with a relapse rate of >50% during glucocorticoid tapering. On average, relapses can occur 1-2 X/year. An isolated rise in the ESR or CRP, without recurrence of PMR symptoms, should not automatically trigger intensification of steroid therapy. Glucocorticoid doses should not be increased to lower acute phase reactants alone. 2. Osteoarthritis (OA) The American College of Rheumatology established 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in knee and hip osteoarthritis: Non-pharmacologic: Cardiovascular (aerobic) and/or resistance land based exercise or aquatic exercise Lose weight if overweight Participate in self-management programs Receive physiotherapy combined with supervised exercise Receive psychosocial intervention Use walking aids as needed Be instructed in the use of thermal agents Knee osteoarthritis might also benefit from medially wedged insoles for lateral compartment OA, tai chi, acupuncture, and transcutaneous electrical stimulation. Pharmacologic: Acetaminophen Oral NSAIDs (Tylenol #3) or tramadol Intraarticular corticosteroid injections

3 Knee osteoarthritis might also benefit from topical NSAIDs. Capsaicin cream, chondroitin sulfate, and glucosamine were not recommended. No recommendations were made regarding hyaluronate injections, duloxetine, or opioids. The clinical implications of obesity have been recognized as far back as the 1700 s: To lengthen thy life, lessen thy meals Benjamin Franklin January 17, April 17, 1790 The prevalence of osteoarthritis (lumbar spine, hips, knees and feet) in obesity doubles compared to a normal BMI. Obesity is an unequivocal risk factor for onset, progression and symptoms of knee OA. The risk of knee OA increases 4-fold and 4.8 fold in obese women and men, respectively. The risk of knee OA increases 15% for each additional kg/ m 2 with a BMI >27. A 10-year study reported a linear relationship between BMI and disabling knee OA. Maintaining an ideal BMI reduces the onset of knee OA, alleviates pain, and disability. An intensive diet and exercise trial for OA randomized 454 obese patients (BMI kg/m 2 ) to: 1. diet (2 meals at 300kcal and 1 meal at kcal) and exercise (moderately intense walking and resistance 1 hour/day 3X weekly); 2. diet only; 3. exercise only. At 18 months, diet and exercise combined provided significant improvement in OA pain and function over diet and exercise alone. To lengthen thy cartilage, lessen thy meals and increase thy exercise Kim Northcott May 25, Fibromyalgia (FM) Fibromyalgia is a polysymptomatic syndrome of variable severity with body pain being a pivotal complaint. At its onset, the pain may be intermittent and localized, vary in location and intensity, have a neuropathic burning sensation, may be affected by factors like weather or stress, and eventually become more persistent.

4 Fatigue occurs in over 90%. Mood disorders are present in 75%. Sleep can be fragmented with difficulty falling asleep, frequent nighttime waking, and awakening tired in the morning, along with restless legs syndrome and sleep apnea. Concentration and memory difficulties have been confirmed in studies. Somatic symptoms are variably present, and commonly include irritable bowel syndrome, migraine headaches, dysmenorrhea, lower urinary tract symptoms, sexual dysfunction, myofascial facial pain, and temporomandibular pain. The 1990 American College of Rheumatology (ACR) fibromyalgia criteria (appendix A) were based on the presence of widespread pain and tender points. The new 2010 ACR fibromyalgia diagnostic criteria eliminate the tender point examination. It recognizes the extent and severity of pain and non-pain symptoms as a central part of the syndrome. The painful regions can be determined by the physician or the patient recording the locations of pain (Pain Location Report appendix B, or Pain Diagram - appendix C). The non-pain symptoms necessitate interviewing the patient in sufficient detail for the physician to rate the extent and severity of symptoms in 4 criteria: fatigue, unrefreshed sleep, cognitive problems, and somatic symptoms (FM Criteria Worksheet - appendix D). The Canadian Pain Society and Canadian Rheumatology Association developed recommendations for the rational care of FM ( This involves a paradigm shift with guidelines emphasizing non-pharmacological strategies (2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome: Ideal care incorporates a multimodal approach. The goal is to achieve functioning within a normal life pattern and discourage any culture of disablement. Working patients with fibromyalgia generally have less severe symptoms and better quality of life than those who are unemployed. Pacing and reasonable adjustments in the working environment may improve employment retention. Regularity in scheduling encourages a steady routine and regular sleep pattern. 1. Non-pharmacologic therapies with active patient participation can establish self-management techniques, goal setting, healthy lifestyle habits and regular exercise, acknowledgment of psychological distress when present, and a strong locus of control. Catastrophizing, where situations or symptoms are much worse than they truly are, facilitates chronic pain. Psychological interventions include treating distress and depression in particular. Cognitive behavioural therapy facilitates coping by improving pain-related behaviour, self-efficacy, and physical function, but is costly. Group therapy sessions can incorporate education, psychological intervention, and exercise. Motivational interviewing involves 6 telephone calls over 10 weeks to improve exercise adherence.

5 Other modalities include written emotional expression, psychomotor therapy, meditation-based stress reduction, EMG-biofeedback, and distraction by means of pleasant imagery or guided imagery with audiotaped scripts. Complementary and alternative medicine may include acupuncture (benefit shown when combined with other treatments including exercise and tricyclic antidepressants), Tai-Chi, yoga, or Qijong (similar to Tai Chi but different breathing pattern and meditation showed some benefit up to 4 months), hydrotherapy programs which include a component of exercise (shown to have positive effects). Chiropractic treatment did not show an appreciable benefit. A graduated exercise program is currently recommended as the first step of a multimodal therapy strategy. As a single exercise program has not been shown to outperform another, it can take a number of forms: aerobic, strengthening, water, home based, or group programs. Fibromyalgia patients report poor exercise capacity and subjective muscle pain, but cardiorespiratory fitness is similar to controls, suggesting they overscore their perception of exertion. Encourage patients to choose an activity either land or water based that is enjoyable, easy to follow, convenient, and within budget to improve adherence. Evidence shows that maintaining physical fitness has a continued positive effect on improving the key symptoms of pain, fatigue, depression and quality of life. 2. Pharmacologic therapies offer only modest symptom relief. Medications that address more than 1 symptom offer an advantage. Targeting the most predominant symptom is a useful starting point. Acetaminophen / Tylenol has never been formally studied and its use is likely best for co-morbid conditions eg. osteoarthritis The peripheral action of NSAIDs offers little rational for use when weighed against side effects. Their use is likely best for co-morbid conditions eg. osteoarthritis Opioids can be associated with negative psychosocial effects: unstable psychiatric disorder, substance abuse, and risk of upregulation of opioid receptors causing recalcitrant pain. Tramadol is a weak opioid agonist with greater SNRI than opioid effects and may be useful in some patients. Naltrexone, an opioid antagonist, had no effect on pain sensitivity in a small study. Antidepressants with pain modulating effects by inhibiting descending pain pathways have been shown in all categories (TCAs, SSRI, SNRI) to have a positive effect on pain, fatigue, depression, sleep, and quality of life in a metaanalysis: amitriptyline 13 studies, paroxetine 5 studies, fluoxetine 4 studies, sertraline 1 study, duloxetine 2 studies. Citalopram in 2 studies did not show benefit. Their anticholinergic and antihistamine side effects may limit their use. There is a question regarding their long term effectiveness. Cyclobenzaprine, technically a muscle relaxant, is structurally similar to TCAs with moderate benefit. An early metaanalysis of gabapentinoids, gabapentin and pregabalin, reports a favourable effect on pain, sleep disturbance, fatigue, and overall well-being.

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7 Fibromyalgia Diagnostic Criteria 1) WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. Put a Check to indicate a painful region. Shoulder, Lt. Shoulder, Rt. Hip, Lt. Hip, Rt. Upper Arm, Lt. Upper Arm, Rt. Lower Arm, Lt. Lower Arm, Rt. Upper Leg, Lt. Upper Leg, Rt. Lower Leg, Lt. Lower Leg, Rt. Jaw, Lt. Jaw, Rt. Chest Abdomen Lower Back Upper Back Neck No pain in any of these areas WPI score 2) SS scale score: Fatigue Waking unrefreshed Cognitive symptoms For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale: 0 = no problem 1 = slight or mild problems, generally mild or intermittent 2 = moderate, considerable problems, often present and/or at a moderate level 3 = severe: pervasive, continuous, life-disturbing problems Considering somatic symptoms in general, indicate whether the patient has:* 0 = no symptoms 1 = few symptoms 2 = a moderate number of symptoms 3 = a great deal of symptoms The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12. SS Scale Score Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1) Widespread pain index (WPI) > 7 and symptom severity (SS) scale score > 5 or WPI 3 6 and SS scale score > 9. 2) Symptoms have been present at a similar level for at least 3 months. 3) The patient does not have a disorder that would otherwise explain the pain. * Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms. Draft

8 ID: Today's Date: mm dd yyyy / / 1. Check all the areas in which you have had pain over the last week: Shoulder, Lt. Shoulder, Rt. Hip, Lt. Hip, Rt. Upper Leg, Lt. Upper Leg, Rt. Lower Leg, Lt. Lower Leg, Rt. Lower Back Upper Back Neck Upper Arm, Lt. Upper Arm, Rt. Lower Arm, Lt. Lower Arm, Rt. Jaw, Lt. Jaw, Rt. Chest Abdomen No pain in any of these areas Page 1 Draft

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