Tuesday, July 1, 2014

Fibromyalgia at the EULAR 2014 Meeting in Paris

There always is an abundance of posters and abstracts on fibromyalgia at the international meetings. One has to select a few and leave the rest for more specific discussions.

W. Häuser talked about: “FIBROMYALGIA – WHAT REALLY WORKS? FROM ANCIENT TO RECENT MANAGEMENTS“. He stated: “Multiple systematic reviews of randomised controlled trials (RCTs) demonstrated that no therapy (complementary/alternative, drug, physical, psychological) in FM “really works” in the sense of substantial symptom relief in the majority of patients.“ “…“old drugs” such as amitryptiline or fluoxetine did not differ from “new” drugs such as duloxetine, milnacipran and pregabalin in terms of symptom reduction and tolerability.“ Effects of were comparable to aerobic exercise and cognitive behavioral therapies, only the latter show evidence of sustained positive effects after the end of treatment. As there are no predictors, treatment responders should be treated. “Patients with mild FM do not need a specific treatment.” Häuser refers to the recent guidelines (Canada, Germany, Israel) and comments on drug therapy. "A recent study which combined aerobic exercise with tailored psychological therapies showed promising long-term results.“
Aerobic exercise plus cognitive behavioral therapy has a positive effect in patients, who allow such treatment. We have been treating patients successfully in this way at our centre since the late 1990ies and therefore it’s depressing for me to see one drug study following the next (duloxetine, milnacipran, and pregabalin) and a lack of studies addressing the issue of cognitive behavioral therapy plus aerobic exercise. I’m optimistic that this will change.

A little aside: recently German physicians have been warned about the risk of addiction to pregabalin.

F. Mckenna on: “MANAGEMENT OF FIBROMYALGIA”. Very interesting talk. “Current data [therefore] supports the hypothesis that both fatigue and chronic widespread pain in FM result from abnormalities in sleep architecture in patients with psychological vulnerability, leading to dysfunction in the descending pain regulating system. These data suggest that management of FM should be multifaceted. In addition to physical, behavioural and other psychological therapies, treatment programmes must include active management of sleep pathology.”
Fatigue and sleep have been issues since the beginning of fibromyalgia research, but pain has been addressed more often than fatigue and sleep. I have used tips and recommendation as well as discussions with patients.
Please refer to “Recommendations for a sound sleep 2.0” http://rheumatologe.blogspot.de/2013/06/recommendations-for-sound-sleep-20.html

M.J. Beasley and colleagues presented: “ASSOCIATION BETWEEN ALCOHOL CONSUMPTION AND CHRONIC WIDESPREAD PAIN: RESULTS FROM A POPULATION-BASED CROSS-SECTIONAL STUDY“. Conclusions: “Moderate alcohol consumption was associated with lower CWP (chronic widespread pain) prevalence, and strongly associated with lower levels of disability in those with CWP. A potential biological mechanism is alcohol’s agonist effects on the neurotransmitter γ-aminobutyric acid (GABA), and disruptions to GABA pain inhibitory pathways have been suggested in persons with FM. Further investigation of the mechanism for these associations is required, specifically whether the excess of highly disabling pain in lifetime non-drinkers with CWP can be explained by other lifestyle or psychosocial factors.
The topic fibromyalgia and alcohol has already been discussed. I’ve written a blogpost on “Fibromyalgia and Alcohol as a Treatment?” as there had been a study by C.H. Kim and colleagues with the title: “Association between alcohol consumption and symptom severity and quality of life in patients with fibromyalgia“; link: http://rheumatologe.blogspot.de/2014/04/fibromyalgia-and-alcohol-as-treatment.html.

R. Greiff presented: „PAIN SCHOOL “KNOWLEDGE FOR LIFE” MAKES LIFE EASIER FOR PEOPLE WITH CHRONIC PAIN“. Conclusions: “… “Knowledge for Life” becomes for many of the participants with chronic pain/fibromyalgia a turning point in life. Where there was no hope only despair, there is new belief in their own abilities.“

Methods: We searched Medline, PubMed, Web of Science, EMBASE, and
Results: „3375 studies were found from the literature search. After scrutiny, 204 trials met the inclusion criteria. In total 13,968 participants were included from all trials, (mean age 49.2 years; 95.4% women).“ …  Conclusions: „Although considered a hard-to-treat condition, people with FM treated with placebo can show significant improvement in pain and other outcomes. Several variables influence the magnitude of this effect. Optimisation of such contextual response could have relevance to clinical care.“
I’ve looked at this problem, too. Here are my ideas: http://rheumatologe.blogspot.de/2012/06/fibromyalgia-and-pregabalin-some-ideas.html

M.-A. Fitzcharles and colleagues presented: “REAL-LIFE ASSESSMENT OF THE VALIDITY OF PATIENT GLOBAL IMPRESSION OF CHANGE IN FIBROMYALGIA“. Conclusions: “The results of this analysis suggest that overall, a weak correlation exists between PGIC (Patient Global Impression of Change) and improvement in standard FM outcome measures. Furthermore, FUP (follow-up) duration was identified as a significant confounder of patient perception of disease improvement which could be due to recall bias or survival bias. Altogether, these results have important implications for FM management and designing new instruments assessing outcomes in FM.”

OK, I’ve made a subjective selection of studies / abstracts, and others might stress other studies. But I think the EULAR 2014 Meeting showed, that fibromyalgia still needs research and subsequent consensus. The disparities between researchers/experts and non-rheumatologists/GPs on what fibromyalgia is need to be bridged. I am optimistic for the future as scientific proofs on fibromyalgia accumulate with every meeting.

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