Question: Fibromyalgia vs. Rheumatoid Arthritis Pain - What Factors Determine Treatment?
How can people with both fibromyalgia and rheumatoid arthritis know which condition is causing their pain? What factors or characteristics allow the patient to distinguish between the two conditions? Is there a best course of treatment for people who have both fibromyalgia and rheumatoid arthritis?
Symptoms Which Distinguish Fibromyalgia From Rheumatoid Arthritis
When patients have complaints of hand pain associated with fibromyalgia it may be difficult to distinguish rheumatoid arthritis from fibromyalgia. There are several ways to distinguish. First, rheumatoid arthritis does not typically involve the DIP joint (i.e. distal interphalangeal joint or end joints closest to the nails) so if there is tenderness there, this would favor fibromyalgia or possibly osteoarthritis. Secondly, fibromyalgia is not associated with joint swelling as occurs in rheumatoid arthritis, although patients often complain that their joints feel swollen. The complaint of widespread body pain associated with the typical fibromyalgia tender points would also be consistent with fibromyalgia and not rheumatoid arthritis.
Treatment Recommendations for Patients With Both Conditions
The best course of treatment for patients who have both fibromyalgia and rheumatoid arthritis is to first treat the rheumatoid arthritis since this condition commonly is associated with joint deformity and disability. If it is felt that the rheumatoid arthritis is controlled based on joint exam and measures of inflammation such as sedimentation rate (ESR) and C-reactive protein (CRP), but the patient still complains of pain and fatigue - consider fibromyalgia activity. Focus on improving quality of sleep through increased rest and aerobic exercise. Rule out sleep apnea if clinically significant. Consider medications used for fibromyalgia including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI), and gabanergic medications like Neurontin (gabapentin) or Lyrica (pregabalin).
Cymbalta (duloxetine HCl) was the first serotonin-norepinephrine reuptake inhibitor that was proven to reduce pain in fibromyalgia patients. Savella (milnacipran), a selective serotonin and norepinephrine dual reuptake inhibitor, increases norepinephrine and serotonin activity in the brain.
Answer provided by Scott J. Zashin, M.D., clinical assistant professor at University of Texas Southwestern Medical School, Division of Rheumatology, in Dallas, Texas. Dr. Zashin is also an attending physician at Presbyterian Hospitals of Dallas and Plano. He is a fellow of the American College of Physicians and the American College of Rheumatology and a member of the American Medical Association. Dr. Zashin is author of Arthritis Without Pain - The Miracle of Anti-TNF Blockers and co-author of Natural Arthritis Treatment.