Fibromyalgia & Lupus National Association


Rheumatoid Arthritis and Fibromyalgia

Rheumatoid arthritis is a chronic type of arthritis. Early symptoms of RA include fatigue, joint pain, and stiffness. As it progresses, rheumatoid arthritis symptoms may feel like the flu, with achiness, muscles aches, and loss of appetite. The causes of rheumatoid arthritis are unknown, although there may be a genetic component. Early and effective rheumatoid arthritis treatment can improve the prognosis and may help prevent joint and bone destruction associated with RA.

In recent years, the typical treatments for rheumatoid arthritis relied on combination NSAIDs, such as ibuprofen and aspirin. These drugs reduce swelling and alleviate pain but do little to change the course of the disease. Another class of treatments relied on disease-modifying, antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine. DMARDs work to slow inflammation and can, in many cases, alter the course of the disease. Because of their adverse effects, most doctors reserved these more powerful drugs for patients who failed to respond to other therapies. Now, many physicians are using DMARDs early and aggressively in the hope of slowing disease progression and preventing damage to joints and internal organs.

The most recently approved treatment regimen for rheumatoid arthritis is one that combines the genetically engineered biological drug Remicade (infliximab) with the drug methotrexate. (Not all patients with rheumatoid arthritis can tolerate or respond to methotrexate alone, a standard treatment for the disease.) Remicade is the second in a new class of drugs known as biologic response modifiers, which bind to and block the action of a naturally occurring protein called tumor necrosis factor (TNF), believed to play a role in joint inflammation and damage. Elevated levels of TNF are found in the synovial fluid of rheumatoid arthritis patients.

Remicade, which is administered intravenously by a health-care professional in a two-hour outpatient procedure, was approved by FDA in November 1999 to reduce the signs and symptoms from rheumatoid arthritis in patients who have not experienced significant relief from methotrexate alone.

Approved in November 1998, Enbrel (etanercept) is the first biologic response modifier to receive FDA approval for patients with moderate to severe rheumatoid arthritis. Taken twice weekly by injection, Enbrel was shown to decrease pain and morning stiffness and improve joint swelling and tenderness. In June 2000, the drug's uses were expanded to include delaying structural damage.

One health professional states that Enbrel is an exciting breakthrough because it helps a majority of patients who have not responded to any of the other commonly used therapies. Although it is injected, the treatment can be administered at home. In addition, Enbrel has been shown to be effective for children with the juvenile form of rheumatoid
arthritis. In clinical trials, Enbrel was generally well tolerated, and one of the most common side effects was an injection site reaction.

Both Remicade and Enbrel show promise in treating rheumatoid arthritis, although the long-term risks and benefits of these drugs are unknown.

The first non-drug alternative for adult patients with moderate to severe rheumatoid arthritis and longstanding disease who have failed or cannot tolerate DMARDs was approved by FDA in March 1999. The Prosorba column, which was initially approved in 1987 to treat an immune blood disorder, is a single-use medical device, about the size of a coffee mug, containing a material that binds antibodies and antigen-antibody complexes.

In a two-hour process performed in a hospital or specialized treatment center, a patient's blood is removed and passed through a machine that separates the blood cells from the plasma (the liquid portion of the blood). The plasma is then passed through the Prosorba column, recombined with the blood cells, and returned to the patient. Although this filtering process is believed to remove proteins that may inadvertently attack the joint cells, the mechanism of action of the Prosorba column is not well understood. The treatment is given once a week for 12 weeks. The most common side effects include joint pain and/or swelling, fatigue, hypotension (low blood pressure), and anemia.

Arava (leflunomide) is the first oral
arthritis treatment approved for slowing the progression of rheumatoid arthritis. Although its effects are similar to those of methotrexate, this drug works by a different chemical mechanism, blocking an enzyme in certain lymphocytes (a type of white blood cell that is part of the immune system) and thereby retarding the progression of the disease.

Arava is not a cure, however, and studies have suggested that the drug may cause birth defects. Therefore, its labeling carries a special warning for pregnant women, women of childbearing age, and those who want to become pregnant.

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).

Rheumatoid arthritis and fibromyalgia are two pain conditions that commonly go together. While they're very different conditions, their symptoms can be remarkably similar, making diagnosis difficult.

Women are more likely to get both conditions, and both rheumatoid arthritis (RA) and can strike at any age. Unlike, however, RA causes damage and deformity to the joints.

What is Rheumatoid Arthritis?

RA is an autoimmune disease, which means that your immune system mistakenly attacks healthy tissues as if they were foreign substances. Fibromyalgia is not known to be an autoimmune disease. The course of RA is unpredictable, but after many years about 10% of people with it become severely disabled and have a hard time with even the most basic tasks.

Some cases of RA have prolonged remissions in which symptoms vanish for several years. Others have flares and remissions similar to those of Fibromyalgia. The majority, however, have a chronic, progressive form of RA.

RA can impact any joint and even your organs, but it most often involves the small joints of the hands and feet.

Why Do Fibromyalgia & Rheumatoid Arthritis Go Together?

Researchers don't know what causes either condition, so we don't yet understand for sure why Fibromyalgia and RA go together so often. Studies show, however, that people with RA are more likely to develop Fibromyalgia, but people with Fibromyalgia are no more likely than anyone else to develop RA. Some scientists believe that chronic pain, from RA or other sources, can lead to Fibromyalgia by causing changes in the ways our nervous systems perceive and process pain.

Regardless of why you have both conditions, the pain of RA can trigger Fibromyalgia flares and make your symptoms harder to control.

Diagnosing Rheumatoid Arthritis

A specific blood test called the anti-CCP antibody test can distinguish RA from other forms of arthritis. Your doctor may also order several other tests to confirm the diagnosis and to help determine your prognosis.

Symptoms of Rheumatoid Arthritis & Fibromyalgia

Symptoms of RA and Fibromyalgia can be extremely similar. They both include:

·         Joint pain

·         Symmetrical pattern (pain in the same joint on both sides)

·         Fatigue and loss of energy

·         Depression

RA also can cause symptoms that aren't associated with Fibromyalgia, such as:

·         Joint swelling, with warmth around affected joint

·         Loss of appetite

·         Joint deformity

·         Limited range of motion

Treating Rheumatoid Arthritis

A lot of drugs are available for treating RA. They include:

·         Common pain relievers, such as Tylenol (acetaminophen)

·         Non-steroidal anti-inflammatories (NSAIDs), such as Motrin/Advil (ibuprofen) and Aleve (naproxen)

·         COX-2 inhibitors, such as Celebrex (celecoxib)

·         Glucocorticoids, including prednisone and methylprednisolone

·         Disease-modifying antirheumatic drugs (DMARDs), including Trexall/Rheumatrex (methotrexate), Imuran (azathioprine), and Azulfidine (sulfasalazine)

·         TNF blockers, such as Enbrel (etanercept), Remicade (infliximab) and Humira (adalimumab)

Sometimes, surgery can help people with severe joint damage.

Rheumatoid Arthritis Treatment vs. Fibromyalgia Treatment

If you're taking medications for both RA and FMS, be sure to talk to your doctor and pharmacist about possible drug interactions.

Some FMS experts believe that the corticosteroids sometimes used to treat RA can make FMS symptoms worse. By working closely with your doctor, you should be able to find treatments that work for both of your conditions.

For more on how to decide on the best course of treatment for RA and FMS, read Fibromyalgia vs. Rheumatoid Arthritis Pain - What Factors Determine Treatment?, from Guides to Arthritis Carol & Richard Eustice.

Living With Rheumatoid Arthritis & Fibromyalgia

Both RA and Fibromyalgia can make your life extremely difficult and limit how functional you can be. By finding and following a treatment/management regimen, you may be able to preserve your functionality and independence.

Because both conditions can lead to depression and isolation, it's important for you to have a support system. Keep lines of communication open with your doctor and the people you're close to, and get early help if you think you're becoming depressed. Support groups -- both online and in your community -- may be a big help to you, too.










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