Significant use of non-evidence-based therapeutics in a cohort of Australian fibromyalgia patients

BACKGROUND

Fibromyalgia is a common condition characterised by chronic widespread musculoskeletal pain and central sensitivity features. Appropriate management requires a multidisciplinary approach prioritising non-pharmacological strategies. Evidence-based fibromyalgia medications are not always easily available, effective or tolerated.

AIM

To characterise actual medication usage in Australian fibromyalgia patients.

METHODS

Demographic and clinical data, including medication use information, were gathered by chart review from patients attending the Monash Fibromyalgia Clinic between January 2019 and June 2022. Eligible patients were invited to complete an anonymous questionnaire between June and August 2022 to assess current therapeutic use. The questionnaire assessed fibromyalgia clinical features by using the Revised Fibromyalgia Impact Questionnaire and the 2016 modified American College of Rheumatology Fibromyalgia criteria.

RESULTS

The chart review included 474 patients, and 108 participants completed the questionnaire. Most chart review (78.7%) and questionnaire participants (85.2%) reported using at least one medication for their fibromyalgia. 48.5% of chart review patients and 58.3% of questionnaire participants reported using at least one evidence-based medication, usually amitriptyline, duloxetine or pregabalin. However, the most common individual medications for questionnaire participants were non-steroidal anti-inflammatory drugs (48.2%), paracetamol (59.3%) and opioids (34.3%), with most opioids being typical opioids. Among questionnaire participants, 14.8% reported using cannabinoids, and 70.4% reported using at least one supplement, vitamin or herbal/naturopathic preparation. Not all medication or substance use was recorded during clinic appointments.

CONCLUSION

Fibromyalgia patients engage in various pharmacotherapeutic strategies that are not always evidence-based or disclosed to their treating clinicians.

Central Sensitivity and Fibromyalgia

Fibromyalgia presents with symptoms of widespread pain, fatigue, sleeping and cognitive disturbances as well as other somatic symptoms. It often overlaps with other conditions termed 'central sensitivity syndromes' such as irritable bowel syndrome, chronic fatigue syndrome and temporomandibular disorder. Central sensitisation, mediated by amplified processing in the central nervous system, has been identified as the key pathogenic mechanism in these disorders. The term 'central sensitivity' can be used to collectively describe the clinical presentation of these disorders. Fibromyalgia is highly prevalent in most rheumatic diseases as well as non-rheumatic chronic diseases and if unrecognised results in high morbidity. It is diagnosed clinically after excluding important differential diagnoses. Diagnostic criteria have been developed as tools to help identify and diagnose fibromyalgia. Such tools can fulfill an important need when managing patients with rheumatic disease and other chronic diseases as a way to identify fibromyalgia and improve patient outcomes. Treatment involves an integrated approach including education, exercise, stress reduction and pharmacological therapies targeting the central nervous system. This approach is suitable for all presentations of central sensitivity and some central sensitivity syndromes have additional treatment options specific to the clinical presentation. This article is protected by copyright. All rights reserved.

Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (P_{for interaction} < 0.001) and/or acute coronary syndromes (P_{for interaction} = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.

Long-term outcomes following percutaneous coronary intervention for patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited.

Methods

We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]).

Results

Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR&lt;60 ml/min/1.73m2 in 31% vs 24%), while rates of current smoking were lower (20% vs. 25%), all p&lt;0.05. Lesions were more frequently complex (ACC/AHA type B2/C in 61% vs 57%), required longer stents (&gt;20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p&lt;0.05. 30-day mortality was higher (4.4% vs. 3.3%, p=0.04) mainly owing to higher non-cardiac mortality (1.6% vs. 0.8%, p=0.01). National Death Index-linked long-term mortality was 28% vs. 19% (p&lt;0.01) with mean follow-up 4.6 vs. 5.4 years. Risk of 30-day and long-term mortality (including by indication subgroup) are presented in the Table.

Conclusions

Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes.

Funding Acknowledgement

Type of funding source: None

Key Milestones Contributing to the Understanding of the Mechanisms Underlying Fibromyalgia

The promulgation of the American College of Rheumatology (ACR) 1990 criteria for fibromyalgia (FM) classification has significantly contributed to an era of increased research into mechanisms that underlie the disorder. The previous emphasis on putative peripheral nociceptive mechanisms has advanced to identifying of changes in central neural networks that modulate pain and other sensory processes. The influences of psychosocial factors on the dynamic and complex neurobiological mechanisms involved in the fibromyalgia clinical phenotype are now better defined. This review highlights key milestones that have directed knowledge concerning the fundamental mechanisms contributing to fibromyalgia.

Chronic pain syndromes: overlapping phenotypes with common mechanisms

The common chronic pain syndromes of fibromyalgia, regional pain syndrome, and complex regional pain syndrome have been made to appear separate because they have been historically described by different groups and with different criteria, but they are really phenotypically accented expressions of the same processes triggered by emotional distress and filtered or modified by genetics, psychology, and local physical factors.

Modulation of NMDA Receptor Activity in Fibromyalgia

Activation of the N-methyl-d-aspartate receptor (NMDAR) results in increased sensitivity of spinal cord and brain pathways that process sensory information, particularly those which relate to pain. The NMDAR shows increased activity in fibromyalgia and hence modulation of the NMDAR is a target for therapeutic intervention. A literature review of interventions impacting on the NMDAR shows a number of drugs to be active on the NMDAR mechanism in fibromyalgia patients, with variable clinical effects. Low-dose intravenous ketamine and oral memantine both show clinically useful benefit in fibromyalgia. However, consideration of side-effects, logistics and cost need to be factored into management decisions regarding use of these drugs in this clinical setting. Overall benefits with current NMDAR antagonists appear modest and there is a need for better strategy trials to clarify optimal dose schedules and to delineate potential longer–term adverse events. Further investigation of the role of the NMDAR in fibromyalgia and the effect of other molecules that modulate this receptor appear important to enhance treatment targets in fibromyalgia.

Fibromylagia

BACKGROUND

Fibromyalgia is a common and debilitating condition. The cardinal feature of fibromyalgia is musculoskeletal pain, usually accompanied by other problems, such as fatigue, sleep disturbance and cognitive difficulties. Fibromyalgia commonly coexists with other chronic illnesses and can result in poorer outcomes if untreated.

OBJECTIVE

The objective of this review is to discuss when fibromyalgia should be considered as a diagnosis, how it is diagnosed, the current understanding of the pathophysiology of fibromyalgia and the management strategies available.

DISCUSSION

The features of fibromyalgia are similar to those of many other chronic illnesses, sometimes resulting in diagnostic confusion. Fibromyalgia can co-exist with other disorders and it is important to consider the possibility of fibromyalgia contributing to symptoms in any chronically ill patient.

A study of the prevalence and associations of subchondral bone marrow lesions in the knees of healthy, middle-aged women

OBJECTIVE

Bone marrow lesions (BMLs) have been shown to be associated with pain and progression of knee osteoarthritis (OA) in those with disease. The natural history of BMLs in a healthy population and their role in the pathogenesis of OA are unknown. The aim of this study was to determine the risk factors for BMLs in healthy subjects and the association of BMLs with knee structure.

METHODS

One hundred and seventy-six healthy, adult women with no history of knee injury, or clinical knee OA had magnetic resonance imaging performed on their dominant knee to assess BMLs, tibiofemoral cartilage defects, tibial cartilage volume and bone area.

RESULTS

Thirteen percent of subjects had knee BMLs. The prevalence was higher in the medial tibiofemoral compartment. There was a significant positive association between BMLs and cartilage defects after adjusting for the potential risk factors: age, height, weight and cartilage volume [odds ratio (OR) 1.78 (95% confidence interval [CI] 1.12, 2.82), P=0.01]. BML was positively associated with tibial plateau bone area in the lateral compartment [OR 1.67 (95% CI 1.02, 2.71), P=0.04]. There was no significant association between BMLs and cartilage volume. Independent risk factors for BMLs after adjustment were increasing height [OR 1.18 (95% CI 1.02, 1.36), P=0.02 for lateral compartment] and weight [OR 1.04 (95% CI 1.01, 1.08), P=0.005 for total knee].

CONCLUSION

These data support that BMLs are present in a similar distribution to tibiofemoral knee OA. Their presence is associated with risk factors (height and weight) for knee OA, and the early structural changes of knee OA in subjects without knee pain and thus no clinical disease. Longitudinal studies will clarify whether BMLs relate to the pathogenesis of clinical knee OA.