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D’Amuri A, Greco S, Pagani M, Presciuttini B, Ciaffi J, Ursini F. Common Non-Rheumatic Medical Conditions Mimicking Fibromyalgia: A Simple Framework for Differential Diagnosis. Diagnostics (Basel) 2024; 14:1758. [PMID: 39202246 PMCID: PMC11354086 DOI: 10.3390/diagnostics14161758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/06/2024] [Accepted: 08/10/2024] [Indexed: 09/03/2024] Open
Abstract
Fibromyalgia (FM) is a chronic non-inflammatory disorder mainly characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and a constellation of other symptoms. For this reason, delineating a clear distinction between pure FM and FM-like picture attributable to other common diseases can be extremely challenging. Physicians must identify the most significant confounders in individual patients and implement an appropriate diagnostic workflow, carefully choosing a minimal (but sufficient) set of tests to be used for identifying the most plausible diseases in the specific case. This article discusses prevalent non-rheumatological conditions commonly observed in the general population that can manifest with clinical features similar to primary FM. Given their frequent inclusion in the differential diagnosis of FM patients, the focus will be on elucidating the distinctive clinical characteristics of each condition. Additionally, the most cost-effective and efficient diagnostic methodologies for accurately discerning these conditions will be examined.
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Affiliation(s)
- Andrea D’Amuri
- General Medicine Unit, Medical Department, ASST Mantova, Ospedale Carlo Poma, Str. Lago Paiolo 10, 46100 Mantova, Italy; (A.D.); (M.P.); (B.P.)
| | - Salvatore Greco
- Internal Medicine Unit, Medical Department, Ospedale del Delta, Via Valle Oppio 2, Lagosanto, 44023 Ferrara, Italy;
| | - Mauro Pagani
- General Medicine Unit, Medical Department, ASST Mantova, Ospedale Carlo Poma, Str. Lago Paiolo 10, 46100 Mantova, Italy; (A.D.); (M.P.); (B.P.)
| | - Barbara Presciuttini
- General Medicine Unit, Medical Department, ASST Mantova, Ospedale Carlo Poma, Str. Lago Paiolo 10, 46100 Mantova, Italy; (A.D.); (M.P.); (B.P.)
| | - Jacopo Ciaffi
- Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, 40136 Bologna, Italy
| | - Francesco Ursini
- Medicine & Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, 40136 Bologna, Italy
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Costa A, Lucarini E. Treating chronic stress and chronic pain by manipulating gut microbiota with diet: can we kill two birds with one stone? Nutr Neurosci 2024:1-24. [PMID: 38889540 DOI: 10.1080/1028415x.2024.2365021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
Background: Chronic stress and chronic pain are closely linked by the capacity to exacerbate each other, sharing common roots in the brain and in the gut. The strict intersection between these two neurological diseases makes important to have a therapeutic strategy aimed at preventing both to maintain mental health in patients. Diet is an modifiable lifestyle factor associated with gut-brain axis diseases and there is growing interest in its use as adjuvant to main therapies. Several evidence attest the impact of specific diets or nutrients on chronic stress-related disorders and pain with a good degree of certainty. A daily adequate intake of foods containing micronutrients such as amino acids, minerals and vitamins, as well as the reduction in the consumption of processed food products can have a positive impact on microbiota and gut health. Many nutrients are endowed of prebiotic, anti-inflammatory, immunomodulatory and neuroprotective potential which make them useful tools helping the management of chronic stress and pain in patients. Dietary regimes, as intermittent fasting or caloric restriction, are promising, although further studies are needed to optimize protocols according to patient's medical history, age and sex. Moreover, by supporting gut microbiota health with diet is possible to attenuate comorbidities such as obesity, gastrointestinal dysfunction and mood disorders, thus reducing healthcare costs related to chronic stress or pain.Objective: This review summarize the most recent evidence on the microbiota-mediated beneficial effects of macro- and micronutrients, dietary-related factors, specific nutritional regimens and dietary intervention on these pathological conditions.
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Affiliation(s)
- Alessia Costa
- Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Elena Lucarini
- Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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Zanetti CB, Pontes MAG, de Moura EGH, Domiciano DS. High frequency of gastrointestinal complaints, but insignificant prevalence of gluten-sensitive enteropathies in Brazilian fibromyalgia patients. REUMATOLOGIA CLINICA 2023; 19:374-378. [PMID: 37661115 DOI: 10.1016/j.reumae.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/15/2022] [Indexed: 09/05/2023]
Abstract
INTRODUCTION/OBJECTIVES Coeliac disease (CD) and non-coeliac gluten sensitivity (NCGS) cause symptoms like those seen in patients with fibromyalgia (FM) and functional gastrointestinal disorders. There is no consistent data on frequency of these symptoms and no study performed duodenal biopsies to investigate CD/NCGS in Brazilian FM patients. Therefore, we sought to verify the prevalence of CD/NCGS in FM patients and the association between gastrointestinal manifestations and FM symptoms. MATERIAL AND METHODS Sixty-two individuals with FM (ACR2010) were recruited from FM outpatient clinics of a tertiary hospital. Clinical evaluation included the Widespread Pain Index (WPI), Severity Symptom Scale (SS), Polysymptomatic Distress Scale (PDS), and Fibromyalgia Impact Questionnaire (FIQ). Subjects were screened for the presence of coeliac antibodies and upper gastrointestinal endoscopy (duodenal biopsies) was performed for diagnosis of CD/NCGS. RESULTS 46 (74.2%) women reported at least one digestive symptom: constipation, abdominal distension, loss of weight/inappetence, and nausea/vomiting. Fourteen (31.8%) presented macroscopic duodenitis and 2(4.5%) had duodenal lymphocytic infiltrates, but none met CD criteria. In 1(1.6%) patient NCGS was confirmed. There was association between presence of any digestive symptom and WPI and SS (fatigue, waking up tired, cognition), but no difference on FIQ between patients with and without gastrointestinal symptoms. CONCLUSION Gastrointestinal complaints were frequent and associated with increased degree of polysymptomatic distress in FM patients, but presence of these symptoms was not related to overall impact of FM over different dimensions of the patient's life. Moreover, the prevalence of CD/NCGS was very low. This suggests that screening for CD in Brazilian FM patients might not be cost-effective, since the frequency of CD/NCGS was very low.
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Affiliation(s)
- Caio Bosquiero Zanetti
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Antônio Gonçalves Pontes
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Diogo Souza Domiciano
- Division of Rheumatology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
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Almirall M, Casellas F, Dot J, de Torres I, Segurola H, Marsal S. Prevalence of non-coeliac gluten sensitivity and assessment of the response to gluten-free diet in a cohort of patients with fibromyalgia. Rheumatology (Oxford) 2023; 62:1069-1077. [PMID: 35900154 DOI: 10.1093/rheumatology/keac434] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To establish the prevalence of non-coeliac gluten sensitivity (NCGS) in a cohort of fibromyalgia patients and to evaluate their clinical response to a six-week gluten-free diet (GFD), the improvement in their symptoms, the percentage of diet responders who did not fulfil the diagnostic criteria for NCGS and the baseline characteristics that were associated with diet response and diagnostic criteria fulfilment. METHODS Uncontrolled prospective experimental study in a cohort of patients with fibromyalgia from a specialized hospital unit. The percentage of patients that fulfilled the Salerno Experts' Criteria, that responded to GFD, that improved their symptomatology and baseline characteristics associated with GFD response and diagnostic criteria fulfilment was analysed. RESULTS In total, 142 patients were selected and a NCGS prevalence of 5.6% was observed. A total of 21.8% responded to GFD due to their improvement in intestinal symptoms. In total, 74.2% of the responders did not fulfil the Salerno Experts' Criteria. The presence of diarrhoea and intraepithelial lymphocytosis and lower levels of anxiety were predictive factors of GFD response. No predictive factors of NCGS criteria fulfilment were found due to the low number of discriminators between gluten and placebo. CONCLUSIONS A NCGS prevalence similar to that estimated in the general population was found. A GFD cannot be systematically recommended to all patients with fibromyalgia, although it could be evaluated in those with diarrhoea or intraepithelial lymphocytosis to evaluate if there are improvements in their intestinal symptoms.
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Affiliation(s)
- Miriam Almirall
- Department of Rheumatology, Hospital Universitari Vall d'Hebron.,Rheumatology Research Group, Vall d'Hebron Research Institute
| | | | | | - Inés de Torres
- Department of Pathology, Hospital Universitari Vall d'Hebron.,Department of Morphological Sciences, Autonomous University of Barcelona
| | - Hegoi Segurola
- Nutritional Support Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sara Marsal
- Department of Rheumatology, Hospital Universitari Vall d'Hebron.,Rheumatology Research Group, Vall d'Hebron Research Institute
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Guerin C, Attli B, Cooley K, Hassan S, Sarebanha S, Sadrolsadot P, Chung C. An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:363-372. [PMID: 35100049 DOI: 10.1089/jicm.2021.0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.
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Affiliation(s)
| | - Bisleen Attli
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | - Kieran Cooley
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
- Australian Research Centre in Complementary and Integrative Medicine, University of Technology, Sydney, Australia
- Pacific College of Health Sciences, San Diego, CA, USA
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, Australia
| | - Samah Hassan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Shadi Sarebanha
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
| | | | - Christine Chung
- Canadian College of Naturopathic Medicine, North York, Ontario, Canada
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Dragan S, Șerban MC, Damian G, Buleu F, Valcovici M, Christodorescu R. Dietary Patterns and Interventions to Alleviate Chronic Pain. Nutrients 2020; 12:E2510. [PMID: 32825189 PMCID: PMC7551034 DOI: 10.3390/nu12092510] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022] Open
Abstract
Pain is one of the main problems for modern society and medicine, being the most common symptom described by almost all patients. When pain becomes chronic, the life of the patients is dramatically affected, being associated with significant emotional distress and/or functional disability. A complex biopsychosocial evaluation is necessary to better understand chronic pain, where good results can be obtained through interconnected biological, psychological, and social factors. The aim of this study was to find the most relevant articles existent in the PubMed database, one of the most comprehensive databases for medical literature, comprising dietary patterns to alleviate chronic pain. Through a combined search using the keywords "chronic pain" and "diet" limited to the last 10 years we obtained 272 results containing the types of diets used for chronic pain published in the PubMed database. Besides classical and alternative methods of treatment described in literature, it was observed that different diets are also a valid solution, due to many components with antioxidant and anti-inflammatory qualities capable to influence chronic pain and to improve the quality of life. Thirty-eight clinical studies and randomized controlled trials are analyzed, in an attempt to characterize present-day dietary patterns and interventions to alleviate chronic pain.
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Affiliation(s)
- Simona Dragan
- Department of Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania; (S.D.); (F.B.); (M.V.); (R.C.)
- Institute of Cardiovascular Diseases Timișoara, 13 Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Maria-Corina Șerban
- Department of Functional Sciences, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania
| | - Georgiana Damian
- Department of Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania; (S.D.); (F.B.); (M.V.); (R.C.)
| | - Florina Buleu
- Department of Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania; (S.D.); (F.B.); (M.V.); (R.C.)
| | - Mihaela Valcovici
- Department of Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania; (S.D.); (F.B.); (M.V.); (R.C.)
- Institute of Cardiovascular Diseases Timișoara, 13 Gheorghe Adam Street, 300310 Timișoara, Romania
| | - Ruxandra Christodorescu
- Department of Cardiology, “Victor Babeș” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timișoara, Romania; (S.D.); (F.B.); (M.V.); (R.C.)
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Erdrich S, Hawrelak JA, Myers SP, Harnett JE. Determining the association between fibromyalgia, the gut microbiome and its biomarkers: A systematic review. BMC Musculoskelet Disord 2020; 21:181. [PMID: 32192466 PMCID: PMC7083062 DOI: 10.1186/s12891-020-03201-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The association between fibromyalgia and irritable bowel syndrome is well-established. Alterations in the composition and diversity of the gut microbiome in irritable bowel syndrome have been reported, however, this association is poorly understood in fibromyalgia. Our aim was to summarise the research reporting on the gastrointestinal microbiome and its biomarkers in people with fibromyalgia. METHODS A systematic review of published original research reporting on the gastrointestinal microbiota and its biomarkers in adults with a diagnosis of fibromyalgia was undertaken. RESULTS From 4771 studies, 11 met our inclusion criteria and were separated into four main groups: papers reporting Helicobacter pylori; other gut bacterial markers; metabolomics and other biomarkers, which included intestinal permeability and small intestinal bacterial overgrowth. CONCLUSION The results suggest there is a paucity of quality research in this area, with indications that the gut microbiota may play a role in fibromyalgia within the emerging field of the gut-musculoskeletal axis. Further investigations into the relationship between the gut microbiota, gut dysfunction and fibromyalgia are warranted.
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Affiliation(s)
- Sharon Erdrich
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.
| | - Jason A Hawrelak
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Stephen P Myers
- NatMed Research Unit, Division of Research, Southern Cross University, Lismore, New South Wales, Australia
| | - Joanna E Harnett
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Zylberberg HM, Lebwohl B, Green PHR. Celiac Disease-Musculoskeletal Manifestations and Mechanisms in Children to Adults. Curr Osteoporos Rep 2018; 16:754-762. [PMID: 30350261 DOI: 10.1007/s11914-018-0488-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW We aim to review the current literature on the association of musculoskeletal disorders and celiac disease that is a common disorder, affecting about 1% of the population. Extra-intestinal symptoms and presentations predominate. RECENT FINDINGS While the literature supports an association with reduced bone mineral density and increased fracture risk and celiac disease, there is little evidence supporting associations with other rheumatological conditions. Patients frequently report musculoskeletal symptoms; however, studies of specific disease entities suffer from a lack of standardization of testing for celiac disease and a lack of control groups. Well-controlled, preferably population-based studies are required to further explore a relationship between celiac disease and musculoskeletal disorders.
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Affiliation(s)
- Haley M Zylberberg
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Peter H R Green
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA.
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Abstract
PURPOSE OF REVIEW Fibromyalgia syndrome (FMS) is defined as chronic, widespread musculoskeletal pain and tenderness with concomitant mood and cognitive dysfunction. Several comorbidities have been reported to be associated with FMS. We reviewed the literature concerning the most noteworthy chronic conditions associated with FMS. RECENT FINDINGS There is mounting evidence displaying the concurrence of fibromyalgia and coexisting medical and psychiatric conditions. Such comorbidities may blur the classical clinical presentations and erroneously lead to misinterpretation of disease activity. The recognition of this fact should be underlined, as misrecognition may lead to excessive therapy and avoidable side-effects of medications on the one hand and to a better handling of FMS on the other hand, leading to improved clinical outcomes. SUMMARY A greater proportion of psychiatric and rheumatologic disorders are associated with FMS patients than the population. Consequently, physicians treating patients with either condition should keep in mind that these patients may have such comorbidities and should be treated accordingly.
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Elhami E, Zakeri Z, Sadeghi A, Rostami-Nejad M, Volta U, Zali MR. Prevalence of celiac disease in Iranian patients with rheumatologic disorders. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2018; 11:239-243. [PMID: 30013748 PMCID: PMC6040036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIM Patients with Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), and Fibromyalgia (FM) may have underlying non-diagnosed celiac disease (CD). BACKGROUND The aim of this study was to determine the prevalence of CD in patients with these underlying diseases in Iran. METHODS This cross-sectional study was performed among 300 consecutive patients with SLE, RA, and FM (each group 100 patients) since 2015 to 2017. The blood samples were collected and serum IgA anti-tissue trans-glutaminase (Anti-tTG) level was assessed for all patients. The seropositive patients underwent endoscopy and duodenal/jejunal biopsy according to the Marsh classification. RESULTS Out of 300 investigated patients with mean age of 41.2 years old, 92% of patients with SLE, RA and fibromyalgia were women. Among 100 patients with SLE, only 1 subject (1%), out of 100 patients with RA 3 subjects (3%), and none of the patients with fibromyalgia were seropositive for CD (with overall prevalence 1.4). All four patients were female and categorized as Marsh III. CONCLUSION The results of the study indicated that patients with lupus have the same prevalence, but subjects with RA had three times higher prevalence rate than normal population for CD. Therefore, CD investigation in these individuals can improve their quality of life.
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Affiliation(s)
- Elham Elhami
- Labafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Zakeri
- Labafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Sadeghi
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abstract
Presently, evidence for the efficacy of medications for the treatment of juvenile fibromyalgia syndrome (JFMS) is limited. While there are medications approved by the US Food and Drug Administration (duloxetine, milnacipran and pregabalin) for adults with fibromyalgia syndrome, there are none for the treatment of JFMS. A variety of medications have been prescribed for the treatment of JFMS, including (but not limited to) non-opioid analgesics, opioids, anticonvulsants, antidepressants, and muscle relaxants. Psychological therapies, most prominently cognitive behavioral therapy, are the most evidenced-based treatment modalities for JFMS. A multidisciplinary approach, combining pharmacological, behavioral and exercise-based modalities is currently the standard of care for JFMS. In the future, more stringent randomized, controlled trials with longer follow-up periods are needed in order to determine the long-term efficacy and safety of medications in the treatment of JFMS. Additionally, improved recognition of JFMS will allow for better patient recruitment to permit for adequately powered study designs.
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Affiliation(s)
- Sabrina Gmuca
- Division of Rheumatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 10101 Colket, 3501 Civic Center Blvd, Philadelphia, PA, 19104-3820, USA
| | - David D Sherry
- Division of Rheumatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 10101 Colket, 3501 Civic Center Blvd, Philadelphia, PA, 19104-3820, USA.
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Diagnostic confounders of chronic widespread pain: not always fibromyalgia. Pain Rep 2017; 2:e598. [PMID: 29392213 PMCID: PMC5741304 DOI: 10.1097/pr9.0000000000000598] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/13/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022] Open
Abstract
Although chronic widespread pain is the defining feature of fibromyalgia, a myriad of other conditions may present with similar pain complaint leading to misdiagnosis. Conditions that may mimic fibromyalgia may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. In this review, we examine these various conditions that should be considered in a differential diagnosis and provide direction that will help the clinician differentiate these conditions from fibromyalgia. Introduction: Chronic widespread pain (CWP) is the defining feature of fibromyalgia (FM), a worldwide prevalent condition. Chronic widespread pain is, however, not pathognomonic of FM, and other conditions may present similarly with CWP, requiring consideration of a differential diagnosis. Objectives: To conduct a literature search to identify medical conditions that may mimic FM and have highlighted features that may differentiate these various conditions from FM. Methods: A comprehensive literature search from 1990 through September 2016 was conducted to identify conditions characterized by CWP. Results: Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. Characteristics pertaining to the most commonly identified confounding diagnoses within each category are discussed; clues to enable clinical differentiation from FM are presented; and steps towards a diagnostic algorithm for mimicking conditions are presented. Conclusion: Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM.
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13
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Reply to the comment of Daron et al. entitled "Occurrence of rheumatic symptoms in celiac disease: A meta-analysis". Joint Bone Spine 2017; 84:647-648. [PMID: 28347709 DOI: 10.1016/j.jbspin.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2017] [Indexed: 11/20/2022]
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Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis. Am J Gastroenterol 2017; 112:65-76. [PMID: 27753436 DOI: 10.1038/ajg.2016.466] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Celiac disease (CD) and irritable bowel syndrome (IBS) share similar symptoms, leading to confusion between the two and diagnostic delay. International guidelines recommend screening individuals with IBS for CD, via serological testing. However, studies published recently have cast doubt on the utility of this. We updated a previous meta-analysis examining this issue. METHODS MEDLINE, EMBASE, and EMBASE Classic were searched through to May 2016. Eligible studies recruited adults with IBS according to symptom-based criteria, physician's opinion, or questionnaire data. Tests for CD included IgA-class antigliadin antibodies (AGA), endomysial antibodies (EMA), tissue transglutaminase antibodies (tTG), or duodenal biopsies following positive serology. The proportion of individuals meeting criteria for IBS testing positive for CD was combined to give a pooled prevalence for all studies, and compared between cases with IBS and, healthy controls without (where reported), using an odds ratio (OR) with a 95% confidence interval (CI). RESULTS There were 36 eligible studies, recruiting 15,256 individuals, of whom 9,275 (60.8%) met criteria for IBS. Pooled ORs for positive IgA AGAs, EMA and/or tTG, and biopsy-proven CD in IBS subjects vs. controls were 3.21 (95% CI 1.55-6.65), 2.75 (95% CI 1.35-5.61), and 4.48 (95% CI 2.33-8.60), respectively. There was no increase in ORs for any test for CD among cases with IBS in North American studies, and results were inconsistent in population-based studies. The prevalence of biopsy-proven CD was significantly higher across all subtypes of IBS. Limitations included heterogeneity in some analyses, and few North American studies. CONCLUSIONS Overall, prevalence of positive celiac serology and biopsy-proven CD was significantly higher in subjects with symptoms suggestive of IBS vs. healthy controls. However, the utility of screening for CD in individuals with suspected IBS in North America or in the community is less clear.
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Laszkowska M, Roy A, Lebwohl B, Green PHR, Sundelin HEK, Ludvigsson JF. Nationwide population-based cohort study of celiac disease and risk of Ehlers-Danlos syndrome and joint hypermobility syndrome. Dig Liver Dis 2016; 48:1030-4. [PMID: 27321543 DOI: 10.1016/j.dld.2016.05.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/18/2016] [Accepted: 05/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with celiac disease (CD) often have articular complaints, and small prior studies suggest an association with Ehlers-Danlos syndrome (EDS)/joint hypermobility syndrome (JHS). AIMS This study examines the risks of EDS/JHS in patients with CD. METHODS This cohort study compared all individuals in Sweden diagnosed with CD based on small intestinal biopsy between 1969-2008 (n=28,631) to 139,832 matched reference individuals, and to a second reference group undergoing biopsy without having CD (n=16,104). Rates of EDS/JHS were determined based on diagnostic codes in the Swedish Patient Register. Hazard ratios (HRs) for EDS/JHS were estimated through Cox regression. RESULTS There are 45 and 148 cases of EDS/JHS in patients with CD and reference individuals, respectively. This corresponds to a 49% increased risk of EDS/JHS in CD (95%CI=1.07-2.07). The HR for EDS was 2.43 (95%CI=1.20-4.91) and for JHS 1.34 (95%CI=0.93-1.95). Compared to reference individuals undergoing intestinal biopsy, CD was not a risk factor for EDS/JHS. A stronger association was seen in patients initially diagnosed with EDS/JHS and subsequently diagnosed with CD (odds ratio=2.29; 95%CI=1.21-4.34). CONCLUSIONS Individuals with CD have higher risk of EDS/JHS than the general population, which may be due to surveillance bias or factors intrinsic to celiac development.
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Affiliation(s)
- Monika Laszkowska
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Abhik Roy
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
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16
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Houghton LA, Heitkemper M, Crowell M, Emmanuel A, Halpert A, McRoberts JA, Toner B. Age, Gender and Women's Health and the Patient. Gastroenterology 2016; 150:S0016-5085(16)00183-9. [PMID: 27144622 DOI: 10.1053/j.gastro.2016.02.017] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
Abstract
Patients with functional gastrointestinal disorders (FGIDs) often experience distress, reduced quality of life, a perceived lack of validation, and an unsatisfactory experience with health care providers. A health care provider can provide the patient with a framework in which to understand and legitimize their symptoms, remove self-doubt or blame, and identify factors that contribute to symptoms that the patient can influence or control. This framework is implemented with the consideration of important factors that impact FGIDs, such as gender, age, society, and the patient's perspective. Although the majority of FGIDs, including globus, rumination syndrome, IBS, bloating, constipation, functional abdominal pain, sphincter of Oddi dyskinesia, pelvic floor dysfunction, and extra-intestinal manifestations, are more prevalent in women than men, functional chest pain, dyspepsia, vomiting, and anorectal pain do not appear to vary by gender. Studies suggest sex differences in somatic but not visceral pain perception, motility, and central processing of visceral pain; although further research is required in autonomic nervous system dysfunction, genetics and immunologic/microbiome. Gender differences in response to psychological treatments, antidepressants, fiber, probiotics, and anticholinergics have not been adequately studied. However, a greater clinical response to 5-HT3 antagonists but not 5-HT4 agonists has been reported in women compared with men.
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Affiliation(s)
- Lesley A Houghton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA; Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK.
| | | | - Michael Crowell
- Division of Gastroenterology and Hepatology Mayo Clinic, Scottsdale, Arizona, USA
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Nisihara R, Marques AP, Mei A, Skare T. Celiac disease and fibromyalgia: Is there an association? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 108:107-8. [DOI: 10.17235/reed.2015.3992/2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Tuck CJ, Muir JG, Barrett JS, Gibson PR. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols: role in irritable bowel syndrome. Expert Rev Gastroenterol Hepatol 2014; 8:819-34. [PMID: 24830318 DOI: 10.1586/17474124.2014.917956] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Irritable bowel syndrome (IBS) was previously left poorly treated despite its high prevalence and cost. Over the past decade, significant research has been conducted providing new dietary strategies for IBS management. The 'low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet' has shown symptom improvement in 68-76% of patients. Randomized, controlled trials have now proven its efficacy. The diet, low in poorly absorbed and fermentable carbohydrates, uses dietary restriction and re-challenge to determine individual tolerance to various short-chain carbohydrates. However there may be potential detrimental effects of the diet in the long term, due to potential changes to the gastrointestinal microbiota. Appropriate dietary education and management of the diet is imperative. Future research should focus on the relevance of changes to the microbiota and ways to liberalize the dietary restrictions.
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Affiliation(s)
- Caroline J Tuck
- Department of Gastroenterology, Monash University and Alfred Health, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004 Australia
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19
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Rodrigo L, Blanco I, Bobes J, de Serres FJ. Effect of one year of a gluten-free diet on the clinical evolution of irritable bowel syndrome plus fibromyalgia in patients with associated lymphocytic enteritis: a case-control study. Arthritis Res Ther 2014; 16:421. [PMID: 25160886 PMCID: PMC4177310 DOI: 10.1186/s13075-014-0421-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/08/2014] [Indexed: 12/11/2022] Open
Abstract
Introduction Irritable bowel syndrome (IBS), lymphocytic enteritis (LE) and fibromyalgia syndrome (FMS) are three common disorders. Since a gluten-free diet (GFD) has been shown to be helpful in LE, we aimed to assess its effect in a series of LE patients also diagnosed with IBS and FMS. Methods The study sample comprised 97 IBS plus FMS adult females, of whom 58 had LE (Marsh stage 1), and 39 had a normal duodenal biopsy (Marsh stage 0). All patients fulfilled the Rome III and American College of Rheumatology 1990 criteria. All participants followed a GFD, the effectiveness of which was assessed by changes in the results of several tests, including those of the Fibromyalgia Impact Questionnaire (FIQ), the Health Assessment Questionnaire (HAQ), tender points (TPs), the Short Form Health Survey (SF-36), and the Visual Analogue Scales (VAS) for gastrointestinal complaints, pain and fatigue. Results At baseline, all patients had a poor quality of life (QoL) and high VAS scores. After one year on a GFD, all outcome measures were somewhat better in the Marsh stage 1 group, with a mean decrease of 26 to 29% in the TPs, FIQ, HAQ and VAS scales, accompanied by an increase of 27% in the SF-36 physical and mental component scores. However, in the IBS plus FMS/Marsh stage 0 group, the GFD had almost no effect. Conclusions This pilot study shows that a GFD in the LE-related IBS/FMS subgroup of patients can produce a slight but significant improvement in all symptoms. Our findings suggest that further studies of this subject are warranted.
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Celiac symptoms in patients with fibromyalgia: a cross-sectional study. Rheumatol Int 2014; 35:561-7. [DOI: 10.1007/s00296-014-3110-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/31/2014] [Indexed: 12/28/2022]
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Slim M, Calandre EP, Rico-Villademoros F. An insight into the gastrointestinal component of fibromyalgia: clinical manifestations and potential underlying mechanisms. Rheumatol Int 2014; 35:433-44. [PMID: 25119830 DOI: 10.1007/s00296-014-3109-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/31/2014] [Indexed: 12/14/2022]
Abstract
Fibromyalgia syndrome is characterized by chronic generalized pain accompanied by a broad symptomatologic spectrum. Besides chronic fatigue, sleep disturbances, headaches and cognitive dysfunction that are extensively described in the literature, a considerable proportion of patients with fibromyalgia experience gastrointestinal symptoms that are commonly overlooked in the studies that are not specifically dedicated to evaluate these manifestations. Nevertheless, various attempts were undertaken to explore the gastrointestinal dimension of fibromyalgia. Several studies have demonstrated an elevated comorbidity of irritable bowel syndrome (IBS) among patients with fibromyalgia. Other studies have investigated the frequency of presentation of gastrointestinal symptoms in fibromyalgia in a nonspecific approach describing several gastrointestinal complaints frequently reported by these patients such as abdominal pain, dyspepsia and bowel changes, among others. Several underlying mechanisms that require further investigation could serve as potential explanatory hypotheses for the appearance of such manifestations. These include sensitivity to dietary constituents such as gluten, lactose or FODMAPs or alterations in the brain-gut axis as a result of small intestinal bacterial overgrowth or subclinical enteric infections such as giardiasis. The gastrointestinal component of fibromyalgia constitutes a relevant element of the multidisciplinary pathophysiologic mechanisms underlying fibromyalgia that need to be unveiled, as this would contribute to the adequate designation of relevant treatment alternatives corresponding to these manifestations.
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Affiliation(s)
- Mahmoud Slim
- Instituto de Neurociencias "Federico Olóriz", Universidad de Granada, Avenida de Madrid, 11., 18012, Granada, Spain
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22
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Sherry DD. Response to ‘Remarkable prevalence of celiac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study’. Arthritis Res Ther 2014; 16:402. [PMID: 24528534 PMCID: PMC3978578 DOI: 10.1186/ar4487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rodrigo L, Blanco I, Bobes J, de Serres FJ. Response to ‘Remarkable prevalence of celiac disease in patients with irritable bowel syndrome plus fibromyalgia in comparison with those with isolated irritable bowel syndrome: a case-finding study’ – authors’ reply. Arthritis Res Ther 2014; 16:403. [PMID: 24528551 PMCID: PMC3978895 DOI: 10.1186/ar4488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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