Fibromyalgia & Polymyalgia & Giant Cell Arteritis Flashcards
autoinflammation v autoimmune
where does polymyalgia and fibromyalgia fall
Autoimmune
- B and T lymphcyte activation with autoantibody production
- this is things we can identify the antibodies attacking
- eevated ESR, CRP
- autoantibodies identified
Autoinflammatory
- activaitng the innate immune sytem: cytokine disregulation adn inflammation
- no identification of the autoantibody
- elevaed ESR and CRP
Polymyaliga: falls under an auto-inflammatory condition
fibromyaliga: chronic pain syndrome: not autoimmune, not inflammatory BUT happens commonly in those who have auto-inflammatory and autoimmune conditions
Fibromyalgia
etiology
Etiology
- a chronic condition causing widespread pain
- not autoinflammatory or autoimmune (so ESR and CRP will be negative)
- often secondary condition to other chronic conditions like depression or rheum. disease
- these pt have a heighted reaction to painful stimuli: potentialyl due to SERT, NE and other NT imbalances
- so they DO physically feel pain more than others; not a throw away!!
Consider this in those with rhum. like symptoms but no elevated ESR, CRP or rheum. labs
Fibromyalgia
Symptoms
conditions its assocaited with
Symptoms
- PAIN: all over
- not assocatied with joints swelling or mornign stiffness
- not worse in the morning
- unchanged throughout the da; can be constant
- sometimes worse in the evening
- (this isnt the typicall inflammatory pain of Rheum)
Fatigue: extreme fatigue: cardianl sign
Non-refreshing sleep
Mental Fog & cognitive impairment
Labile Mood
cardinal symptoms for dx. : pain, fatigue, non-refreshing sleep & mental fog
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Conditions Assocaited with Fibromyalgia
- Irritable bowel syndrome
- chronic pelvic pain
- irattibale or overactive bladder
- chronic HA, migraines
- anxiety and depression
- considered to be central sensitivity syndromes
Fibromyalgia
Diagnosis
CARDINAL SYMPTOMS
- pain
- non-refreshing sleep
- mental fog
- fatigue
Clinical Diagnostic Criteria for Fibromyalgia
(widespread pain index)
- a sheet where they can check off where they feel the pain and show it on a body diagram
symptom severity score index
- Fatigue
- Waking unrefreshed
- Cognitive symptoms
other symptoms area
- check off related things
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diagnosis made when….
1. Pt. doesnt have a disorder explainign better
2. symptoms present at this level of pain for 3+ months
3. widespread pain scale score of 12
Fibromylagia
treatment
FDA approved Treatmetn
- pregabalin (anticonvulsant)
- duloxetine (SNRI)
- milnacipran
unfortunately these just dont work, in studies they barely work better than a placebo
OFF label: Amytripyline (TCA) can help a little bit more
NON- PHARM
- acupuncture
- biofeedback
- chiropractor
- CBT very helpful
- hydrotherapy
- meditation
- mindfulness
Briefly describe the central sensitivity syndromes and the fibrmyalgia pain theories
bioloigcal set point for pain and sensory processing that is a threshold lower than other people
additionally, hypersensitivty to stimuli and hyperresponsiveness of teh CNS
- HPA axis related
- NT imbalance related
often ahve a continous painful stumli: OA, obestiy, etc. increasing pain stimuli always
so they’re are a predisposition to take pain and process it differently and more negatively
how is the pain in polymyalgia rheumatica and giant cell different thatn fibromyalgia
in PMR and Ginat cell: these is elevated ESR and CRP on lab exams
- they have no muslce and joint pain with no visable or active inflammation in the joint but the labs are positive
Polymyalgia Rheumatica
etiology
symptoms
Etiology
- inflammatory disease (autoinflammatory-not autoimmune as we dont ahve an autoantibody to link it to)
- affected > 50 and women
- involving the peri-articualr strcutures of the UPPER and LOWER SHOUDLER GIRDLES: shoulders and hips!!!!!!
- causes muscle pain, stiffness and functional limitations
- highly responsive to steroids
if left untreated: PMR can lead to vasculitis
Symptoms
- pain, non-inflammatory (not red, swollen, etc) but painful with movement and stiff
- pain in the shoudler girdle and pevlic girdle joints
- postive ESR and CRP but no autoanitbodies
Polymyalgia Rhemuatica
treatment
Treatment
- goal is to maintain remission sing lowest dose of steroids: they’re higly responsive to steroids
- want to reduce risk of vasculitis
- & maintain disease remission without flairs after steroids are stopped
prednisone is the monotherapy of choice for PMR
- often times they do so so well so quickly after initing steroids
can consider adding a DMARD if they’re steroid dependent (like you tried to taper them off and they flaired, we would want to swtich them to this so they’re not on chronci steroids)
DMARD of choice = methotrexate
PMR to Giant Cell Arteritis pipline
GCA etiology
if PMR isnt controlled it can progress to vasculitis = specifically GCA
- 40% and 60% of CGA report symptoms of PMR (girdle pain)
- spectrum of disease but can occur separately too
Etiology
- vasculitis; inflammation of the blood vessels
- commonly in the scalp and head; arteries over the temple
- but DOESNT have to be there
Giant Cell Arteritis
Clinical Manifestations
Diagnosis
Clinical Manifestations
- temporal HA and
- tongue discoloration
- can go to the aorta!!! and any other vessel within the body
Diangosis
- a biopst of the temporal artery is the only way to confirm the disease
- see then giant cells and inflammation on the biopsy slide: disrupting the internal elastic laminae of the vessel
Giant Cell Arteritis
Treatment
Treatment
- high dose steroids until clinical remission is achieved
- IV pulse therapy of methylprednisode can be used if there is ischemic involvement (severe)
- then want to slowly taper
unfortunately, difficult so
- Tocilizumab can be used: but HIGH GI toxicity risk and perofrations
other meds (not FDA approved)
- IL-23
- JAK 1
- methotrexate
- abatacept
