Rheumatologists and primary care physicians tend to use different diagnostic tests and prescribe different treatments for fibromyalgia syndrome, survey results indicated.
A large fraction of physicians in both groups did not follow the American College of Rheumatology (ACR) 1990 criteria for diagnosing fibromyalgia, Dr. Terence W. Starz and his associates reported in a poster presentation at the annual meeting of the American College of Rheumatology.
Questionnaires e-mailed to 199 rheumatologists throughout Pennsylvania and 183 primary care physicians in the Southwestern portion of the state were returned by 74 (37%) of the rheumatologists and 89 (49%) of the primary care physicians.
Both groups agreed that it takes more time to manage patients with fibromyalgia than other patients.
Rheumatologists were significantly more likely to use ACR criteria to diagnose fibromyalgia (56, or 76%) compared with primary care physicians (50, or 56%). The two groups also differed significantly in the use of tests to measure levels of vitamin D, rheumatoid factor, antinuclear antibody, and anti-cyclic citrullinated peptide (anti-CCP) antibody.
They reported similar rates of testing for thyroid function, metabolic profile, and human leukocyte antigen B27.
“We need to determine which ones of those should be utilized, because they're very expensive. A vitamin D level can cost up to 0. Anti-CCP is very expensive. They're not included” in the current ACR diagnostic criteria, said Dr. Starz, a rheumatologist at the University of Pittsburgh Medical Center.
Vitamin D levels were ordered by 36 rheumatologists (49%) and 15 primary care physicians (17%). Tests for rheumatoid factor were ordered by 43 (58%) and 68 (76%), respectively. Rheumatologists were more likely to measure anti-CCP level (24, or 32%) than were primary care physicians (5, or 6%) but less likely to test for antinuclear antibody (45, or 61%, compared with 68, or 76%, of primary care physicians).
The groups reported similar perceptions about the pathophysiology of fibromyalgia. About three-fourths said fibromyalgia is both a medical and psychological condition, less than 20% said it's solely a medical condition, and less than 10% said it's solely psychological.
Nearly all physicians in both groups prescribed exercise and physical therapy to treat fibromyalgia, but use of other therapies differed significantly. Cognitive therapy was prescribed by 39 rheumatologists (52%) and 26 primary care physicians (29%). Nonsteroidal anti-inflammatory drugs were prescribed by 42 rheumatologists (57%) and 75 primary care physicians (84%).
“The data on NSAIDs, though, are not very good for fibromyalgia,” Dr. Starz said.
The primary care physicians were significantly more likely to use selective serotonin reuptake inhibitors (68, or 76%) compared with rheumatologists (42, or 57%).
Rheumatologists were more likely to treat with cyclobenzaprine (64, or 86%), or alpha-2-delta ligands such as gabapentin or pregabalin (64, of 86%) compared with primary care physicians (50, or 56% and 59, or 66%, respectively).
The use of selective norepinephrine reuptake inhibitors for fibromyalgia was similar between groups.
“There's not nearly enough focus on sleep hygiene and sleep treatment” for patients with fibromyalgia, Dr. Starz added.
An estimated 5 million people in the U.S. have fibromyalgia, more than the combined total of patients with RA (1.3 million), SLE (322,000), scleroderma (49,000), polymyalgia rheumatica (228,000), and gout (3 million), he said.
The investigators reported no conflicts of interest.