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Reader Comments on: Fibromyalgia Is Not a Rheumatologic Disease Anymore See reader comments on this article and provide your own.
Readers are encouraged to respond to George Lundberg, MD, Editor in Chief of The Medscape Journal of Medicine, for the editor's eyes only or for possible publication as an actual Letter in the Medscape Journal via email: glundberg@medscape.net
To the Editor,
I just read Dr. Griffing's article on fibromyalgia.[1]
I recently moved to Freehold, New Jersey, and went to a highly recommended internist. After giving him my medical history, he told me that I didn't have fibro-Cfids. I was diagnosed in November 2000 by a rheumatologist from NYU Medical Center in New York, after going to many doctors who couldn't find anything wrong with me. Most family practitioners and internists have no idea what this syndrome is and how to treat it. I have learned to live with fibro-Cfids with my medications thanks to my doctors, who do not think I'm crazy. Most practitioners and internists do not know how to treat a patient with dignity. Education is the key factor here. Patients who have this syndrome have a very hard time finding a doctor who knows about this syndrome and who is not keeping his or her head in a sandbox. Rheumatologists are the only lifeline that people like me have for our sanity. It is a very long process and until other doctors are educated about this syndrome, will we never let go of our rheumatologists.
Ms. Egna,
I agree that we need to start educating more healthcare providers about “fibro.” There are not enough rheumatologists to go around. I am glad you have found the doctors and medicines to treat your problem.
One caveat, however. I would not lump “Cfids” with fibro; these are very different medical problems (that may be worthy of another editorial). Thank you for your interest in the editorial.
To the Editor,
The George T. Griffing, MD, Medscape editorial, “Fibromyalgia Is Not a Rheumatologic Disease Anymore,” begins with, “Think of your last patient with difficult-to-treat fibromyalgia: Aren't they all? Did you refer that person to a rheumatologist?”[1] He goes on to argue that this practice may be outdated because, in part, existing evidence shows fibromyalgia is not an inflammatory disease and currently approved medications are not anti-inflammatories.
The criteria for diagnosing fibromyalgia was established by the American College of Rheumatology.[2] I am aware of no other accepted means at arriving at a diagnosis save conducting the history and physical they prescribe. The approval of one pharmaceutical for its treatment and recent studies demonstrating the efficacy of some psychiatric medications have not established new diagnostic criteria. No physician is doing any patient a favor by giving him or her a diagnosis of fibromyalgia without adhering to accepted diagnostic practice.
It is questionable to argue that fibromyalgia is not rheumatologic because it is not inflammatory. There is scant evidence on the etiology of fibromyalgia. Rheumatoid arthritis (RA) is an autoimmune disorder. Inflammation is a prominent symptom, but patients with RA in remission have little or no inflammation. Should we refer patients with RA to immunologists? Sjögren's syndrome is caused by lymphocytes invading glands. It is not a connective tissue disease. Should we refer patients with Sjögren's syndrome to hematologists?
I have worked with patients diagnosed with fibromyalgia in conjunction with rheumatologists. It is not news to me or to those physicians that certain psychiatric medications including antiepileptics, mood stabilizers, and antidepressants are efficacious in the treatment of chronic pain. There is plenty of research to back that up and it's not new. The goal of fibromyalgia treatment is to increase pain tolerance in a chronic condition, which typically responds to aggressive interdisciplinary interventions.
Success in treating fibromyalgia is not measured in absence of symptoms, it is measured in tolerance of them, lack of disability, and quality of life. Dr. Griffing states all patients with fibromyalgia are “difficult-to-treat.” I disagree. Patients aren't difficult to treat, including those with fibromyalgia. Sometimes their illnesses don't respond to the treatment we provide. At that point we could choose to get frustrated and label them difficult-to-treat or we could choose to get busy and perhaps get a consult.[1]
Thank you for your comments, and it sounds like you and your colleagues are very experienced and successful with your patients who have fibro. I would like to congratulate you on your accomplishments! The rest of us, however, find this disease very difficult, and most of my rheumatology friends are not very excited when I tell them I would like to refer one of my fibro patients to them.
It would not serve any purpose to argue whether rheumatologists should or should not see patients with fibro, and that was not the point of my editorial. I think healthcare providers, regardless of specialty, who are interested enough to provide the very best care, should be the “fibro experts.”
I would like to correct a small but important point in your letter. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia are not “diagnostic” criteria. As stated in their article, these criteria are for purposes of standardizing clinical and epidemiologic investigations. They have never been validated for diagnostic purposes. Indeed, as you are aware, patients with fibro hurt everywhere – not just in those 18 tender points.
The Editor,
I had the opportunity to read this Medscape article[1] and certainly respect Dr. Griffing's opinion, but beg to differ in the sense that, if treating physicians follow his suggestion not to refer patients to rheumatologists, many of those who may also have rheumatologic problems will be sorely neglected.
I am one of those people with rheumatologic comorbidities: diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and plain old gosh darn painful osteoarthritis.
So, shame on Dr. Griffing!
First, let me say I am happy you found a rheumatologist who is taking good care of your problems. The intent of my article was not to discourage referrals to rheumatologists, but to suggest a paradigm shift of our thinking about this disease. The current thinking about fibro is that it is not your typical immunologic or inflammatory disorder (like ankylosing spondylitis or osteoarthritis), but instead is a neurologic problem of central pain processing. The only connection with rheumatology, therefore, is historical. I appreciate your interest in the editorial.
