Is It Fibromyalgia, Psoriatic Arthritis, or Both?

Psound Bytes™ Transcript: Episode 174

Release date: September 13, 2022

“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”

Shiva: My name is Shiva Mozaffarian and joining me today for a discussion about fibromyalgia and psoriatic arthritis is renowned rheumatologist Dr. Evan Siegel with Arthritis and Rheumatism Associates in Rockville, Maryland where he specializes in the treatment of psoriatic arthritis and other spondyloarthropathies such as ankylosing spondylitis. Dr. Siegel is also a Clinical Assistant Professor of Medicine at Georgetown University School of Medicine and a member of the National Psoriasis Foundation’s Medical Board. Dr. Siegel has been involved in the development of treatment guidelines through GRAPPA which is the international Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, guidelines from the American College of Rheumatology and the National Psoriasis Foundation,  as well as United Rheumatology.

Welcome back to Psound Bytes™ Dr. Siegel! You previously spoke about domains of psoriatic arthritis in episode #72, which was such a great episode to record. Today we're here to discuss fibromyalgia and psoriatic arthritis. Let's first start with a basic question for our listeners. What is fibromyalgia and what are typical symptoms of this disease?

Dr. Siegel: Well, thank you for having me back again. I really appreciate the opportunity to discuss this. So yeah, let's talk about fibromyalgia. Fibromyalgia is a fairly common disorder. We think it probably occurs in maybe two or three percent of the general population, but a much higher prevalence in patients with other immune related inflammatory disorders like psoriatic arthritis where it may occur in as much as 15 to even 22% of patients. Fibromyalgia is a widespread pain disorder involving diffuse musculoskeletal pain involving the upper and lower extremities and the trunk above and below the waist. It is often associated with significant fatigue and sleep disturbances. In fact, we believe that the sleep disturbances may be central to the development of fibromyalgia. Many patients have cognitive disturbances. There are often associated psychiatric symptoms like some depression and anxiety. Many patients have diffuse numbness and tingling pins and needles type sensations in all four extremities. These are known as paresthesias. It's very common to have headache associated as one of the symptoms of fibromyalgia and many patients will have irritable bowel type symptoms such as alternating diarrhea, constipation or abdominal cramping. So it's a very diffuse disorder with widespread symptoms that often occurs more in women than in men. It's important to remember that this is not an immune mediated disease. This is probably more a neurologically mediated disorder.

Shiva: So given what you just mentioned, can you address the key differences and similarities between fibromyalgia and psoriatic arthritis?

Dr. Siegel: Well, psoriatic arthritis and fibromyalgia are very different disorders even though they can coexist. So psoriatic arthritis we believe is an immune mediated disorder that causes significant inflammation in the joints and at points where tendons and ligaments insert into bones as well as spinal inflammation. All of these areas and the pain and dysfunction is secondary to inflammation and psoriatic arthritis can cause significant joint destruction. Fibromyalgia, on the other hand, is a diffuse, widespread pain disorder that is not associated with inflammation. However, it does cause this diffuse musculoskeletal achiness, and often areas of point tenderness.  It's associated with fatigue, as can be seen in inflammatory disorders like psoriatic arthritis. So there are many similarities in terms of pain and fatigue and sometimes even cognitive dysfunction, however the background etiology is very different.

Shiva: And does fibromyalgia also come and go with flares such as psoriatic arthritis?

Dr. Siegel: Yeah. So both disorders can have episodes of flare and remission. Psoriatic arthritis tends to be much more persistent when untreated. It can cause, as I said, joint destruction when untreated. But some people do experience significant flares of skin and joint disease, as well as periods where they are not in as much pain. Fibromyalgia also has flares and remission. Often secondary to stressful times in a person's life, so stress can bring out a flare of fibromyalgia. Worsening of sleep patterns can bring out a flare of fibromyalgia, and we often we'll see a flare of fibromyalgia after a viral illness or other non-associated sickness that then will bring out the more diffuse musculoskeletal achiness and worsening of fatigue.

Shiva: Can you please comment on what might be the potential cause for development of fibromyalgia versus psoriatic arthritis? You mentioned fibromyalgia is not an immune mediated disease whereas psoriatic arthritis is.

Dr. Siegel: Correct. So, of course at the very root of it, we don't exactly know what the cause of either of these disorders is. We know that psoriatic arthritis is immune mediated with activity of the immune system causing significant inflammation. Fibromyalgia is very different, and we believe the cause of fibromyalgia is actually neurologically mediated. It appears that it's an amplification of neural signaling, so overproduction of nerve signals, possibly from some peripheral source. For example, in psoriatic arthritis or rheumatoid arthritis, we can see the inflammation causing a chronic pain stimulation. But in fibromyalgia or what we like to call central sensitivity syndrome, those nerve signals begin to become amplified. As they become amplified, they continue to stimulate the areas in the spinal cord that receive those pain signals. Those can become hypersensitive as well and transmit increased pain signals to the brain. The brain has a mechanism to try to tamp down those increasing pain signals, but that may be abnormal in fibromyalgia as well so that inhibitory function is gone or decreased.  That may relate to some neural chemicals like serotonin and norepinephrine. There are a number of other neurochemicals involved in the pain signaling like substance P. All of these may be either upregulated or downregulated, which then causes this overall hypersensitivity. One can really think of the problem in fibromyalgia as the volume knob being turned up. So there are many pain signals. Just routine muscle function, routine bowel function that may be able to signal the brain, but that generally our volume knobs are turned down low enough that we don't really appreciate those signals. In fibromyalgia, the volume is turned up and the sensitivity is turned up so that many of those normal functions of muscle and bowel and other portions of our body are felt in a very abnormal way. And that may be amplified by the chronic pain associated with inflammatory disorders.

Shiva: That’s such a great analogy,  thank you. So what’s the prevalence of fibromyalgia among people with psoriatic arthritis? Is it possible to have both diseases? And are there risk factors for developing fibromyalgia? You mentioned stress and poor quality of sleep earlier.

Dr. Siegel: So, the prevalence of fibromyalgia in people with psoriatic arthritis is probably somewhere around 15 to 25%. It's not uncommon for both diseases to be present in the same person. So certainly yes, it is possible to have both diseases, and that can really complicate the process of treating these diseases. As far as risk factors, we do think that there are genetic risk factors for developing fibromyalgia. Certain genes that predispose people to developing this disorder. It does run in families, so there's a higher risk of developing fibromyalgia if you have a first degree relative with fibromyalgia. And then chronic uncontrolled inflammation may put people at risk of developing fibromyalgia or any type of chronic, uncontrolled pain can begin to cause this central sensitivity. Certainly in patients who for other reasons have sleep abnormalities, that is a big risk factor. So in just general population studies where this has been looked at, patients with sleep disorders are at much higher risk for fibromyalgia. There have even been some demonstrations where people have been put into a sleep laboratory and just awakened multiple times per night and over a period of one to two months, they begin to develop some of the signs and symptoms of fibromyalgia. So, sleep quality seems to be a big risk factor for fibromyalgia.

Shiva: Interesting. So is it possible to have other forms of arthritis in addition to fibromyalgia and psoriatic arthritis?

Dr. Siegel: Well, sure. And that's really all always the challenge to the rheumatologist to determine exactly what types of arthritis a person has. So even in the diagnosis of psoriatic arthritis, there can be the concomitant fibromyalgia that we're talking about. But sometimes people also develop osteoarthritis, so people can have particularly as they get older, wear and tear type of arthritis or osteoarthritis associated and superimposed to their psoriatic arthritis. And of course, that would be treated differently.

Shiva: Since some of the symptoms such as pain and fatigue are the same for both diseases, how challenging is it to diagnose fibromyalgia versus psoriatic arthritis? You mentioned there are definite differences. So what factors impact diagnosis?

Dr. Siegel: Right, so this is a major challenge across the board in primary care, but even for many experienced rheumatologists, it's very difficult to differentiate fibromyalgia from some of the manifestations of psoriatic arthritis. As I mentioned, psoriatic arthritis often affects areas where tendons attach to bone. This can be at the lateral epicondyle, the region people develop tennis elbow or in the regions around the knee. These are also areas that tend to be very tender with fibromyalgia. So, the problem in diagnosing fibromyalgia is that many of the manifestations of psoriatic arthritis can look just like fibromyalgia, and many of the characteristics of fibromyalgia and findings in fibromyalgia can look just like psoriatic arthritis. Sometimes it's very difficult just through physical examination to differentiate the two. Often, I'll check for this enthesitis or inflammation of tendons right at the lateral elbow, but that's also a spot that's very commonly tender in fibromyalgia. So some rheumatologists will separate these two using diagnostic ultrasound. With ultrasound, you can tell whether there's inflammation in a particular structure. You can do an ultrasound of the tendon attachment point and see is there inflammation or is there not inflammation? If there is not inflammation, then this is more likely to be fibromyalgia than ah psoriatic arthritis. The chronic fatigue is also a very thing to differentiate between fibromyalgia and psoriatic arthritis. Many patients with psoriatic arthritis because of pain will have sleep disorders as well. One of the things I try to look at is if it appears that all the inflammation is under control with therapy. Let's say I've put somebody on to a biologic therapy and overall the inflammation that I was previously seeing in the joints in their hands and their wrists, maybe at the Achilles tendon insertion and other areas that they were complaining of before. If those have all gotten better, if some of their laboratory tests showing inflammation have improved and they're still complaining of widespread pain, that's when I begin to think, could this be fibromyalgia? If they're still complaining of significant sleep disorders, even though inflammation seems to be under control, that's when I began to think about fibromyalgia. This is very important in deciding about treatments, because if a patient comes in and I've been treating them with what should be an effective agent, and it appears that the inflammation has come under control but they’re still complaining that they're in significant pain, changing their medicine for psoriatic arthritis is not gonna do a thing for fibromyalgia. And we have to think about the appropriate treatment mechanisms for the fibromyalgia rather than abandoning the medication that may actually be working for their inflammation.

Shiva: And how important is it to get the right diagnosis?

Dr. Siegel: It is essential to get the right diagnosis because we do have many medications now that are effective for psoriatic arthritis. But once we give up on one because it has been ineffective, we generally never go back to it. And you can really move through all the different medications if you're changing them for the wrong reason. So as I mentioned earlier, it's very important to understand whether fibromyalgia may be complicating psoriatic arthritis because many of the methods that we use to check for efficacy of a particular medication, both in clinical trials and in clinical practice have been shown not to be as effective in determining improvement in patients with fibromyalgia. So once again, if somebody has developed fibromyalgia on top of their psoriatic arthritis and even though may have their inflammation well controlled and the immune portion of their disease under control, they still feel miserable because they have these symptoms of widespread pain and fibromyalgia. But changing around the medications is not going to help them. Instead, we have to find other ways of treating them for the fibromyalgia.

Shiva: And who should someone see to diagnose either fibromyalgia and/or psoriatic arthritis?

Dr. Siegel: Well, that's easy. Patients should see their rheumatologist or should see a rheumatologist because rheumatologists are experts in the treatment of both psoriatic arthritis and fibromyalgia. In fact, when the two are combined, it's very important that a rheumatologist treat this and not a pain management specialist or somebody who's going to just try to suppress pain.

Shiva:  Such good advice. So what treatments are used for fibromyalgia versus psoriatic arthritis? Since they have different pathways for how the diseases develop, it seems that treatment choices would also be different.

Dr. Siegel: Right. So the first line treatment for fibromyalgia really are some lifestyle changes and non- medication interventions. And that is number one trying to address sleep patterns. That can be done with lots of lifestyle changes. Avoiding screen time before bed. Making sure that the bedroom is cool and dark and quiet and a number of other things that can be done to improve sleep.  Sometimes medications may be necessary to help with sleep patterns as well. We often use a medication called Trazodone or sometimes Amitriptyline that can help to improve sleep patterns. In addition, one of the most important non-medication interventions is the addition of aerobic exercise and some stretching programs. So most importantly is the aerobic exercise and I always encourage and insist that my patients with fibromyalgia begin a aerobic walking program for 15 to 30 minutes absolutely every day. This is so important that I often say to my patients if you have not exercised aerobically and you're about to go to bed, walk back and forth in the hallway of your home rapidly enough to get your heart beating for 15 minutes. Exercise really does seem to change some of the abnormal nerve pathways that are so important in the development of fibromyalgia. So, improvement in sleep patterns and an aerobic exercise program are the first line therapy. After that we do try to treat with medications that can address these abnormal nerve pathways, and that includes medicines like tricyclic antidepressant medications like amitriptyline and sometimes cyclobenzaprine. And if those aren't helping or sometimes even as a first line agent, we'll use one of the SNRI’s. So these were originally developed as antidepressant medications. These are medicines like Duloxetine sometimes known as Cymbalta® or milnacipran which the brand name is Savella® which can actually interfere by allowing more production and more presence of norepinephrine and serotonin, which we think are very important in the suppressive pain pathways that I was talking about before. We very much want to avoid the use of narcotics in fibromyalgia. Narcotics tend to make things worse. So the more specific medications that I mentioned are better choices. Often the help of a physical therapist will make a big difference. So teaching stretching as well as relaxation exercises and guiding the aerobic exercise program. And finally some psychotherapy therapy intervention specifically cognitive behavioral therapy has been shown to be very, very helpful. In fact, in some trials, it's been shown to be more helpful than any medication interventions in fibromyalgia. So lots of different things can be done, but we don't want to just throw a medication right off the bat at this. Many of the treatment modalities in fibromyalgia need patient acceptance and patient participation, like these exercise programs, and real focus on improvement in sleep patterns.

Shiva: And are there any other options for lifestyle changes?

Dr. Siegel: Yeah, so in addition to things we already mentioned, really stress reduction is key and trying to identify points of stress throughout the day. Things that can both increase anxiety and depression that can interrupt sleep. It's also helpful to add some meditation during the day can be helpful.  And as I mentioned earlier, working with a cognitive behavioral therapist often can add a lot of things to day-to-day regimens that can make a big difference.

Shiva: That’s such a great point, thank you. I know research continues to discover the relationship between the two diseases and why they develop. Is it possible to prevent either psoriatic arthritis or fibromyalgia?

Dr. Siegel: No. It's an interesting question because there are several initiatives that are going on right now looking at whether it might be possible to prevent the development of psoriatic arthritis in patients with psoriasis.  Possibly by identifying triggers and another trial specifically looking at whether treating with a biologic agent that decreases inflammation in the earlier phases of psoriasis before people even have symptoms of psoriatic arthritis and whether that may prevent the progression to psoriatic arthritis. As far as prevention of fibromyalgia it's difficult. I think that getting inflammatory diseases under control early on so that there's not the chronic stimulation of pain from the inflammation and really focusing on appropriate sleep patterns and making sure there's some exercise throughout the week on a daily basis, even though joints are painful,  really can be helpful in trying to prevent the development of fibromyalgia. And I guess in both diseases early recognition is key so that either disorder doesn't become really set in and more difficult to treat.

Shiva: Well thank you so much for being here with us today Dr. Siegel. The information you’ve shared has been so interesting. Do you have any final comments for our listeners today about psoriatic arthritis and fibromyalgia?

Dr. Siegel: I guess I would just reiterate how common it is in 15 to 20%, maybe one in five to one in six people may have superimposed fibromyalgia. So patients should be aware that that may be a complicating feature, especially if they're on therapy, but don't seem to be improving. And this should be brought up to their rheumatologist whether this is a possibility. Many of these lifestyle issues that we talked about should be pursued by patients with psoriatic arthritis to prevent the superimposed fibromyalgia. And just raising the awareness is key, and that awareness needs to be raised for patients and quite frankly to physicians as well.

Shiva: And that's why we're here today.  

Dr. Siegel: Right.

Shiva: Thank you Dr. Siegel for taking time to address fibromyalgia and psoriatic arthritis. This podcast was so informative! I hope our listeners who may be experiencing some of the issues you mentioned will follow-up with a health care provider soon. For more information about managing chronic pain email our Patient Navigation Center at education@psoriasis.org or call (800) 723-9166, option 1 today. As a reminder, you can find Psound Bytes CME episodes at psoriasis.org/cme-library and finally thank you to our sponsors who provided support on behalf of this Psound Bytes™ episode through unrestricted educational grants from AbbVie, Amgen, Bristol Myers Squibb, Janssen, Lilly and Pfizer. 

We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Google Play, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.  

This transcript has been created by a computer and edited by an NPF Volunteer.