Tuesday, July 24, 2012

Fibromyalgia at the EULAR 2012

There have been more than 70 studies/abstracts on fibromyalgia at the EULAR 2012 in Berlin. It´s impossible to evaluate all of them.

W. Häuser and colleagues gave a very good overview on "comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia". I have already used some of these results in treatment and shall later introduce them in detail.

W. Häuser1, E. Nüesch2, P. Jüni2. 1Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany; 2Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
Conclusions: We deem the small advantages of GABA-analogues and SNRIs over placebo of questionable clinical relevance. Our results do not necessarily support EULAR-recommendations, which currently favour drug therapy over other treatment options. (2). We found a potentially important benefit of aerobic exercise and multicomponent therapy in the management of FMS, which is in line with the recommendations of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) in Germany (3).

Additional large scale randomised trials of high methodological quality of promising non-pharmacological interventions, such as aerobic exercise and multicomponent therapy, are warranted.

S. Metyas an colleagues looked at drug combination therapy. More drugs more effects. Nothing is said concerning adverse events or the fact that people are drugged. The authors could show a reduction in symptoms. So in their conclusion the authors ask for larger, prospective trials to test their conclusion and to assess safety and tolerability of combination therapy.

S. Metyas1, M. Ibrahim1, E.C. Ortiz2, S. Maher2, D. Arkfeld1. 1University of Southern California, Los Angeles, United States; 2Rheumatology, University of Southern California, Los Angeles, United States
Conclusions: Treatment with combined pharmacotherapy significantly improved fibromyalgia severity and associated symptomatology. Combination therapy is synergistic in their effects and yields greater results in multiple symptom domains compared to that of monotherapy. Larger, prospective trials should be developed to test this conclusion and to assess safety and tolerability of combination therapy.

S.L.K. Yuan and colleagues looked at shiatsu in patients with fibromyalgia. The group size is much too small (N=17 per group) and the shiatsu group received 16 sessions of shiatsu lasting 50 minutes, twice a week, while the control group simply received educational guidance through a booklet. If the authors conclude, that staitsu "is effective in improving pain, tenderness and sleep quality in fibromyalgia patients", I must disappoint them. With this kind of study design you proof anything. The control group didn´t receive as much attention as the stiatsu group. A acceptable, not good control group would have received a sham shiatsu (not double blinded!).

S.L.K. Yuan, A.A. Berssaneti, A.P. Marques. Department of Physical Therapy, Speech Therapy and Occupational Therapy, University of Sao Paulo, Sao Paulo, Brazil+
Conclusions: The results indicate that the Shiatsu technique is effective in improving pain, tenderness and sleep quality in fibromyalgia patients.

E. Choy gave a lecture on "How to treat: fibromyalgia". I´ll comment some of his ideas. And as he is a good presenter, I´ll also attend one of his next lectures. Even if I disagree in some parts, his lectures give stimulus to test where you stand yourself.

E. Choy. Department of Rheumatology, Cardiff University School of Medicine, Cardiff, United Kingdom

"These subgroups of patients with FM are likely to respond differently to different treatment strategies, ..."
But is hasn´t been shown that the proposed subgroups have an impact on treatment strategies. That is still to come.
"... treatment should be tailored to the individual, addressing their particular needs and targeting their most distressing symptoms."
I fully agreee, but wouldn´t agree if it comes to drugs.
"Patient education is a key aspect of management as for any chronic medical condition."
Yes and No. Yes, by all means patients need to be educated about their condition. No, education alone doesn´t chance anything. So, education is a needed basis, but then you have to structure other approaches on this basis.
"Explaining underlying pathophysiology reduces frustration and promote coping as well as self-management."
Yes. This is what I do in the educational part of therapy.
"FM patients are equally able to carry out exercise as healthy people, at levels tailored to each individual."
Exercise can help to overcome fear avoidance. It should be an integral part of therapy. But it needs individual tailoring as E. Choy also said. Depressive avoiders are to be addressed differently than happy endurers.
"Cognitive behavioural therapy has been shown to improve pain and function in FM either as sole therapy or in combination with exercise."
Cognitive behavioural therapy shows better results in combination with exercise.
"Tramadol has been shown to reduce pain in FM. It acts centrally and inhibits norepinephrine and serotonin re-uptake ..."
So tramadol works more in the anti-depressive region. It comes with lots of adverse events, to name the most common: nausea.
"Non-steroidal anti-inflammatory drugs, corticosteroids and opioids appear less effective in FM."
What a pharma friendly statement! NSAIDs, corticosteroids, and opiods as well as a long list of drugs have shown to be not effective in fibromyalgia.
"Pregabalin, duloxetine and milnacipran have been licensed by the Food and Drugs Administration in the US for the treatment of FM although none has been licensed in Europe."
And I hope it stays this way as F. Wolfe has shown that effect sizes of these drugs are small or even non existant. Adverse events outreach effects.
"Recent positive trial of sodium oxybate in FM suggests that impaired sleep may be of pathogenic importance in FM[3], therefore improving sleep quality in FM will be an important treatment strategy for future research."
In the ancient beginnings of fibromyalgia research Modolfky has shown that impaired sleep is important in fibromyalgia. Sodium oxybate is a drug designed for the treatment of narcolepsy. Patients with narcolepsy have other needs than patients with fibromyalgia.

B. Hamnes and colleagues looked at "effects of a one week multidisciplinary inpatient self-management programme for patients with fibromyalgia". The background for this study is that self-management programs with or without exercise showed benefits in some outcome parameters for more than 6 months. This study shows only short term effects. It refelects the educational aspect of the intervention. Education itself is important but doesn´t chance itself. We have looked at this issue in 1999-2001 [Valentin, Th., L.M. Kirsch, A. Clasen, G. Bender, B. Kahlfuß, K. Koch: Was taugt die Patientenschulung „Fibromyalgie“ in der Rheumatologie? Die Ergebnisse einer Langzeitstudie. Zeitschrift für Rheumatologie (61), Supplement 1, 2002, S. I/123.].

B. Hamnes1, I. Kjeken2, P. Mowinckel2, K.B. Hagen2,3. 1Hospital for Rheumatic Diseases, Lillehammer; 2National Resource Centre for Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital; 3Department of Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
Conclusions: This study shows that in patients with fibromyalgia the SMP has a small short-term effect on skills and behavior that are important for managing and participating in health care (EC-17).

There are lots of other studies and I might find the time to work through these and present them here.

1 comment:

  1. Fibromyalgia symptoms
    may intensify depending on the time of day -- morning, late afternoon, and evening tend to be the worst times. Symptoms may also get worse with fatigue, tension, inactivity, changes in the weather, cold or drafty conditions, overexertion, hormonal fluctuations (such as just before your period or during menopause), stress, depression, or other emotional factors.