SP0119 SEARCHING FOR PATHOLOGY; HOW HARD SHOULD WE LOOK?
Authors: Ernest Choy
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> The 1990 American College of Rheumatology (ACR) classification criteria for Fibromyalgia (FM) was intended to facilitate research by defining a homogenous patient population [1]. Two key features of the criteria are tender point examination and exclusion of other conditions that may cause widespread pain. This led to the view that FM is a diagnosis of exclusion. This is no longer the case in 2019. <h3>Results:</h3> In 2010, the ACR published provisional criteria for the diagnosis of FM [2]. These allowed FM to be diagnosed by using questionnaire removing the need for tender point examination. One of the major advantages of the criteria is that the diagnosis of FM can be made by primary care physician and the first-line treatment be initiated without referral to secondary care. Such an approach was recommended by the Canadian guidelines [3], which recommended "patients should undergo a physical examination which should be within normal limits except for tenderness on pressure of soft tissues however the specific tender point examination according to the 1990 ACR diagnostic criteria is not required to confirm a clinical diagnosis of fibromyalgia". Furthermore, it stated that "Fibromyalgia should be diagnosed as a clinical construct, without any confirmatory laboratory test, and with testing limited to simple blood testing including a full blood count, erythrocyte sedimentation rate, C-reactive protein, creatine kinase, and thyroid stimulating hormone. Any additional laboratory or radiographic testing should depend on the clinical evaluation in an individual patient that may suggest some other medical condition." However, many primary care physicians do not feel competent/confident to exclude other rheumatic conditions by physician examination. Over the last decade, comorbid FM is increasingly recognized in many chronic musculoskeletal diseases including patients with inflammatory arthritis. A systematic review found that the prevalence of FM is 21%, 13% and 18% in RA, axSpA and PsA respectively [4]. Patients with comorbid FM have higher diseases activity score and more severe pain. In 2016, the ACR diagnostic criteria for FM were modified and stated that "A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses." [5]. <h3>Conclusion:</h3> The motion that "FM is a diagnosis of exclusion" is no longer valid. FM should be a positive diagnosis and does not exclude other rheumatic diagnosis. <h3>References:</h3> [1] Wolfe F, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160-72. [2] Wolfe F, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62:600-10. [3] Fitzcharles MA, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18(3):119-26. [4] Duffield SJ, Miller N, Zhao S, Goodson N. Concomitant fibromyalgia complicating chronic inflammatory arthritis: a systematic review and meta-analysis. Rheumatol (Oxford). 2018;57:1453-1460. [5] Wolfe F, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46:319-329. <h3>Disclosure of Interests:</h3> Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, and Union Chimique Belge, Consultant for: Abbvie, Amgen, AstraZeneca, Biogen, BMS, Boehringer Ingelheim, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmacuetical, GlaxoSmithKline, Hospita, ISIS, Jazz Pharmaceuticals, Janssen, MedImmune, Merrimack Pharmaceutical, Merck Sharp &amp; Dohme, Napp, Novimmune, Novartis, ObsEva, Pfizer, Regeneron, Roche, R-Pharm, SynAct Pharma, Sanofi-Genzyme, Tonix and Union Chimique Belge, Speakers bureau: Amgen, BMS, Boehringer Ingelheim, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp &amp; Dohme, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, and Union Chimique Belge