Fibromyalgia – Responses to Methotrexate and Steroids

Old McGill study found initial impressions of doctors and rheumatologist were wrong 2/3 of time and in particular inflammatory arthritis cases are missed.

Fitzcharles, M‐A et al. “Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals.” Rheumatology 42.2 (2003): 263-267. http://rheumatology.oxfordjournals.org/content/42/2/263.full

This leaves a reservoir of inflammatory cases classified as Fibromyalgia and responding to methotrexate and prednisone.

Omoigui, S., A. Fadare, and C. Ogbechie.
Relief and Resolution of Fibromyalgia Symptoms with Low Dose Methotrexate–The Origin of Pain is Inflammation and the Inflammatory Response.
Rheumatology 4.129 (2014): 2161-1149.

https://www.longdom.org/open-access/relief-and-resolution-of-fibromyalgia-symptoms-with-low-dose-methotrexate-the-origin-of-pain-is-inflammation-and-the-inflammatory-response-2161-1149-4-129.pdf

• 2 cases of refractory Fibromyalgia
• Dramatic relief with methotrexate 10 mg once weekly with folic acid
  There is a foundation in the States
  Fibromyalgia Arthritis Centers of America
  that is treating FM patients with prednisone and claims just as much response as with treatment for rheumatoid arthritis. They claim to be able to reduce prednisone to trivial doses several times a week and avoid toxic side effects.
  sites seems to have died and all I can find is:
  https://archive.jsonline.com/business/pressrelease/Fibromyalgia–Arthritis-patients-can-improve-their-quality-of-life-in-three-weeks-152723845.html/

Comment -Inflammatory issues would be suspect if:

1. Family History of active arthritis – Rheumatoid etc.
2.  Severe pains 6-10/10 –  not your usual FM
3. Morning stiffness significant and 30 minutes +
4. belt line sacroiliac pains that is positive with SI provocation tests
5. pains worse at night
6. pains worse with rest – stiffens up
7. response to an NSAID/arthritis pill could be very helpful
8. some elevations in ESR/CRP that I found ignored by rheumatologists
9.  Typical ankylosing spondylitis progression – had back pain since 20’s – insidious and continuous
10. Celiac, wheat intolerance, Microscopic colitis or bad irritable bowel,  -2/3 of established celiac cases have scan evidence of sacroliitis:
    Rheumatol Int. 2010 Feb;30(4):455-60.
    Back pain and sacroiliitis in long-standing adult celiac disease: a cross-sectional and follow-up study.
    Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór G. http://www.ncbi.nlm.nih.gov/pubmed/19504097
11. History of red eye iritis

A trial of high dose steroids for 4 days might be helpful if not diabetic. Or trial of methotrexate if liver functions good.  I use between 10-40 mg dexamethasone/day – the latter dose representing the 10oo mg methylprednisolone IV pulse therapy as per:
Molenaar, D. S., P. A. Van Doorn, and M. Vermeulen.
Pulsed high dose dexamethasone treatment in chronic inflammatory demyelinating polyneuropathy: a pilot study.
Journal of Neurology, Neurosurgery & Psychiatry 62.4 (1997): 388-390.
http://jnnp.bmj.com/content/62/4/388.full.pdf

Idea that prednisone does not help came from a very early study:

Clark, S., E. Tindall, and R. M. Bennett.
A double blind crossover trial of prednisone versus placebo in the treatment of fibrositis.” The Journal of rheumatology 12.5 (1985): 980-983
http://europepmc.org/abstract/med/3910836

What was not made clear was one case did recover on prednisone and was thought to have an undifferentiated active arthritis – so their statement that steroids did not work at all is a lie. 221 studies refer to this study and propagate this lie.

I see fibromyalgia subjects that are in severe pain and unresponsive to medications. I feel these inflammatory cases are over-represented in this group and are absolutely desperate for a doctor that has brains enough to look for inflammatory patterns. Some of my worst cases are now improved on methotrexate although you have to watch liver functions particularly. Recently became aware of a very painful-morning stiff female case that was even HLA-B27 positive with a family history of active arthritis and was still told had Fibromyalgia by Rheumatologist

Addendum – New study using MRI of spine found at least 1/10 have evidence of spondyloarthritis:
Ablin, Jacob N., et al.
Prevalence of Axial Spondyloarthritis Among Patients With Fibromyalgia: A Magnetic Resonance Imaging Study With Application of the Assessment of SpondyloArthritis International Society Classification Criteria.
Arthritis care & research 69.5 (2017): 724-729.
http://onlinelibrary.wiley.com/doi/10.1002/acr.22967/full

“Sacroiliitis was demonstrated among 8 patients (8.1%) and ASAS criteria for diagnosis of axial SpA were met in 10 patients (10.2%). Imaging changes suggestive of inflammatory involvement (e.g., erosions and subchondral sclerosis) were demonstrated in 15 patients (17%) and 22 patients (25%), respectively. The diagnosis of axial SpA was positively correlated with increased CRP level and with physical role limitation at recruitment.”