fibromyalgia and hashimoto's disease

[mille125]

I have noticed recently that a lot of my patients who have been sent to me for "fibromyalgia" actually seem to have hashimoto's disease. I order thyroid peroxidase antibodies (among other labs) for all of my patients who have a diagnosis of fibromyalgia without an adequate workup. I have seen a lot of these patients with thyroid peroxidase antibodies that are 10-15 times normal. Has anyone else found this to be the case?


My second issue is that I have had a lot of trouble getting endocrinologists to get involved. First of all there is a shortage of endocrine guys and they are very busy. They also seem very reluctant to treat these patients. To me, it seems that these patients would warrant treatment with thyroid hormone even in the face of normal TSH (because they have antibodies). It seems to me that it would be somewhat out of my scope to prescribe synthroid to these patients. What does the forum think about this? Has anyone else run into this dilemma.

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[PMR 4 MSK]

I have noticed recently that a lot of my patients who have been sent to me for "fibromyalgia" actually seem to have hashimoto's disease. I order thyroid peroxidase antibodies (among other labs) for all of my patients who have a diagnosis of fibromyalgia without an adequate workup. I have seen a lot of these patients with thyroid peroxidase antibodies that are 10-15 times normal. Has anyone else found this to be the case?


My second issue is that I have had a lot of trouble getting endocrinologists to get involved. First of all there is a shortage of endocrine guys and they are very busy. They also seem very reluctant to treat these patients. To me, it seems that these patients would warrant treatment with thyroid hormone even in the face of normal TSH (because they have antibodies). It seems to me that it would be somewhat out of my scope to prescribe synthroid to these patients. What does the forum think about this? Has anyone else run into this dilemma.

The prevalences and incidence of fibro compared to Hashimoto's has to be a huge ratio. I've not ordered thyroid antibodies in a fibro w/u, but I do get TSH.

I don't practice outside my scope, and I seem to narrow what I consider my scope of practice as time goes on. Punt to PCP if endocrine doesn't want to play.

 

[mille125]

The prevalences and incidence of fibro compared to Hashimoto's has to be a huge ratio. I've not ordered thyroid antibodies in a fibro w/u, but I do get TSH.

I don't practice outside my scope, and I seem to narrow what I consider my scope of practice as time goes on. Punt to PCP if endocrine doesn't want to play.

TSH is typically normal because antibodies are made against thyroid hormone that is present in normal quantities...thus you typically dont see a rise in TSH...

 

[Aether2000]

Mille, thanks for the tip...I will look for this...

 

[lobelsteve]

As well as the normal TSH folks, I see a lot of folks on Synthroid or Levoxyl with improved numbers but no change in symptoms. As long as their PCP or Endo doesn't mind- I sprnkle in 30 grain of Armour thyroid as a 1 month trial and if effective have them talk to their PCP/Endo aout the difference.

Armour is crack for the hypothyroid patient. My Endo does not like it. But the patient's love it. Improvement in mood, weight loss, libido, and general well being- risks include anxiety, diarrhea, cardiac (the biggie) issues, sweating. It's certainly not for everybody.

 

[Tenesma]

i think we are starting to play with fire when we start branching out into other disciplines - but the argument could be made that a patient with chronic pain similar to fibromyalgia should have a full rheumatologic and endocrine lab battery just to rule out treatable diseases...

knowing my patients, it probably wouldn't improve outcome or success - but intellectually it would be helpful

 

[lobelsteve]

i think we are starting to play with fire when we start branching out into other disciplines - but the argument could be made that a patient with chronic pain similar to fibromyalgia should have a full rheumatologic and endocrine lab battery just to rule out treatable diseases...

knowing my patients, it probably wouldn't improve outcome or success - but intellectually it would be helpful

So what do you do when their total T comes back at 20 and they have been on opioids for 5 years? Managing a side effect is part of managing the Rx. Of course, if you don't write for any drugs, you never have these problems. My patients are sent to me to uncover the source of their pain, and do everything I can to treat it.

This approach works for me. It is in my training, I am comfortable with everything I assess and prescribe for. When I get uncomfortable, I have experts down the hall to turn to.

 

[mille125]

Very interesting points.. I think that if I polled 100 pain doctors, greater than 90 would say that prescribing synthroid is outside of a pain doctor's scope. I dont have any scientific evidence of this but have talked informally with many of my collegues about this point. With that said, thyroid hormone is a very benign treatment and would probably help these patients. Your main worry is a medical legal one. If something did go wrong, I think that you would have a hard time saying that your action was usual and customary in a court of law. You may have more leeway in a rural area. However, if you multidisciplinary group has an endocrinologist, you are in a tougher situation on the stand.


Algos.....please let me know what you find in a few months after you screen some of your fibromyalgia patients. Autoimmune disorder is very prevalent in this group. In my population I have found SLE to be the most common diagnosis of secondary fibromyalgia and hashimotos to be second (ahead of RA). It seems that a lot of patients do improve with treatment of the primary disorder. I have one hashimoto patient who did see an endo who did treat her. Antithyroid Abs were 20 times normal and TSH and T3/T4 were normal. She was prescribed thyroid hormone and feels 85% better now.



Any other thoughts?

 

[Tenesma]

lobel - that is a very far reaching statement (and by the way, i do prescribe medications - they just aren't narcotics)... with just a little flavor of arrogance.

frequently patients are NOT sent to pain specialists for true diagnostic purposes (even though we assume that role when it comes to spine related complaints) - they are sent for managing the pain.

The chronic testicular pain patients have already been worked up by the urologists... The chronic abdominal pain patients have already been worked up by general surgeons, GIs, GYNs, etc... The chronic knee pain s/p TKR has already been worked up by the orthopods... I would be surprised that you "uncover" their true diagnoses...

The chronic non-specific "I hurt everywhere" crowd is by all means the crowd with the least likely chance of uncovering a true diagnosis - and if you were to diagnose African Sleeping Sickness (I had a patient who brought an internet print-out last week - she was convinced of her own self-diagnosis 🙂 ), or Hashimoto's - then assuming the treatment for that condition, then you are really treading on thin ice...

why don't we start prescribing Rocephin for Lyme dz, Methotrexate for RA, Synthroid for hypothyroidism??? this is a lot of risk to assume with little training (even though you could argue rocephin and synthroid are pretty benign).

now, if this is an area of expertise for you - ie: thyroid dysfunction and muscular hypersentivity (aka fibro), then go for it -

but i would argue that for most pain physicians, we should know our limits and know when to refer out - this is the beauty of western allopathic medicine.

as far as managing the side-effects of chronic opioid exposure, that is one thing - but i ain't prescribing or recommending testosterone unless an endocrinologist goes along with the plan... [ as an aside - surprisingly the patients who always want testosterone for their chronic opioid lifestyle are the guys who are already jacked up like Ahrnold.]

i appreciate Mille's insight into this phenomenon and will screen a bit more for this out of my own intellectual curiosity...

*** What is really interesting is that there is a total scam artist about 100 miles from me who treats on a cash-basis all kinds of conditions with naturopathic/hormonal/homeopathic treatments - she has been on probation with the board a multitude of times - and has destroyed quite a few lives (of course she sells all the products as well for a little cash on the side)... she ROUTINELY prescribes Armour Thyroid for anybody who complains of even a tiny bit of fatigue and diagnoses everybody with Hashimoto's... by the time the patients come to me they are usually: cachectic, wired, nauseated and financially devastated...

 

[lobelsteve]

lobel - that is a very far reaching statement (and by the way, i do prescribe medications - they just aren't narcotics)... with just a little flavor of arrogance.

frequently patients are NOT sent to pain specialists for true diagnostic purposes (even though we assume that role when it comes to spine related complaints) - they are sent for managing the pain.

The chronic testicular pain patients have already been worked up by the urologists... The chronic abdominal pain patients have already been worked up by general surgeons, GIs, GYNs, etc... The chronic knee pain s/p TKR has already been worked up by the orthopods... I would be surprised that you "uncover" their true diagnoses...

The chronic non-specific "I hurt everywhere" crowd is by all means the crowd with the least likely chance of uncovering a true diagnosis - and if you were to diagnose African Sleeping Sickness (I had a patient who brought an internet print-out last week - she was convinced of her own self-diagnosis 🙂 ), or Hashimoto's - then assuming the treatment for that condition, then you are really treading on thin ice...

why don't we start prescribing Rocephin for Lyme dz, Methotrexate for RA, Synthroid for hypothyroidism??? this is a lot of risk to assume with little training (even though you could argue rocephin and synthroid are pretty benign).

now, if this is an area of expertise for you - ie: thyroid dysfunction and muscular hypersentivity (aka fibro), then go for it -

but i would argue that for most pain physicians, we should know our limits and know when to refer out - this is the beauty of western allopathic medicine.

as far as managing the side-effects of chronic opioid exposure, that is one thing - but i ain't prescribing or recommending testosterone unless an endocrinologist goes along with the plan... [ as an aside - surprisingly the patients who always want testosterone for their chronic opioid lifestyle are the guys who are already jacked up like Ahrnold.]

i appreciate Mille's insight into this phenomenon and will screen a bit more for this out of my own intellectual curiosity...

*** What is really interesting is that there is a total scam artist about 100 miles from me who treats on a cash-basis all kinds of conditions with naturopathic/hormonal/homeopathic treatments - she has been on probation with the board a multitude of times - and has destroyed quite a few lives (of course she sells all the products as well for a little cash on the side)... she ROUTINELY prescribes Armour Thyroid for anybody who complains of even a tiny bit of fatigue and diagnoses everybody with Hashimoto's... by the time the patients come to me they are usually: cachectic, wired, nauseated and financially devastated...

I use Doxycycline for Lymes and it is a 30-60 day course. No effect on her pain, but it cleared up her acne. Only 4/10 IGG's positive on testing.😀

Maybe our training was a little different...

As far as testosterone replacement for opioid induced hypogonadism (257.2)- that is creating a problem and punting. I am quite comfortable with all of my adjuncts. I do not manage any patients chronic disease not directly related or with close proximty to their pain. I do not read EKG's, CXR's, or play around with HTN, BPH, DM, CAD, Chol, etc.

Frankly I am disappointed in the acusatory nature of the thread especially when mentioning "scope" issues. It may be better to ask, "What training have you had?", "What kind of informed consent do you give when offering testing and medications for conditions like thyroiditis, autoimmune disorder NOS, etc?"

Have you ever written for plaquenil? Why not? When the rheum kicks them to you with an ESR=60, ANA neg, and a RF + but with the wrong titer numbers, do you reach for a bottle of Lortab/Celebrex and say thats all I got? Because I provide advice to the patient that there is more out there. We may trial Medrol, Plaquenil (remember to send them to Optho), and a new rheum to assist.

Nope, no African Sleepers. Had a case of Chagas- but the ID guys took care of that. I do find many interesting things in my patients- but only because I am looking really hard. I like it as much as they do, even if we have no cure or good treatment- sometimes its validation that makes them fel better.

Where do we want to draw the line on RX? None, Opioids, SMR's, NSAIDs, Steroids, AED's, SSRI, SNRI, BZD's, Sleep agents, ABX post procedure (be wary of Cipro if they are on Zanaflex (absolute contraindication)?

I'm not a cowboy or a pioneer, and I know when to punt. /rant off/

 

[Tenesma]

fair enough... i am glad that your training was broad enough to help you feel comfortable with managing these other issues...

out of curiosity, how do the local referring doctors react? how do the rheums, etc, react? do they see this as an adjunct or do they see it as stepping on their toes.

 

[lobelsteve]

fair enough... i am glad that your training was broad enough to help you feel comfortable with managing these other issues...

out of curiosity, how do the local referring doctors react? how do the rheums, etc, react? do they see this as an adjunct or do they see it as stepping on their toes.

They have given up on the patients and turf them to me for "whatever you can do for them". If the clinical picture changes- increased ESR, new swelling in joints, better insurance to allow for better DMARDs, they go back to the rheum. If the Armour works, they go back to the PCP for further evaluation. If the Endo is managing them for anything, I tell the patient about Armour and let the Endo decide. I have written for Armour (qty 7) if the Endo said no- but the patient and I had an exhausting discussion about risks and benefits and what to do if it worked. She was going to get a new Endo if it worked- but it didn't make her feel any better.

My gray areas are how soon do they need to visit the spine surgeons office with: 3-4/5 motor, intact sensation, reduced DTR? I will squirt in my medicine, but if this is not a PROGRESSIVE deficit I want them seen in days not a week. If it is PROGRESSIVE, I want them seen in hours not days.
Many of the surgeons in my area think that when they come from the pain clinic, there is no urgency. I've sent two out in the last week that needed at least a microdisk if the steroids and time didn't do enough. Both had large disks in the foramen with neurologic findings as above. One was L3, the other L4. One guy did not have any pain, but his leg just didn't work right....

I'm happy to try anything that has some clinical data where the benefits can outweight the risks.

 

[mille125]

Steve,

I was not implying that you are a cowboy or a pioneer. In fact, I think that you are a very good doc and would be honored to have you take care of myself or a family member that needs your services. I do feel however that we all need to be careful about what you are calling scope issues. I feel very qualified and confident about handling all of the issues that you just outlined. As you know, bad things do happen in medicine. Sometimes we cause it. Sometimes it is just bad luck. Given the blame oriented society that we live in, I feel that it would be harder to defend a case where a patient had an anaphylatic response to doxycyline if you wrote the script compared to the PCP. I feel that the attorneys of Scumbag LLC would imply that this treatment is not within the usual practice of most pain docs. Perhaps your training and expertise and frequent usage of the medication would mitigate their charges. It just seems like a lose situation especially in a multispecialty practice with other specialists available. We all work very very hard and it is tragic when all that we work for is threatened by a scumbag attorney who is looking to make a fast buck off of an unfortunate situation. Just my opinion..........

 

[Tenesma]

interesting you mention weakness

i used to send all my patients with motor weakness to the surgeons as SUPER-URGENT --- and interestingly, they either get sent back to me for another ESI or they would schedule for a discectomy in a few weeks -

i have only had two patients who were operated within 24 hours of a referral and both of those were because i sent them to the ER (one was cord compression and the other was a flail hand after a HUGE disc herniation)....

i just don't get it... and the surgeons all have different rationales but nothing that makes good sense

 

[Ligament]

I do not prescribe DMARDs, nor do any of the pain docs I've trained with at two pain programs, but if you do that Steve I respect it. Kudos. 🙂

 

[ampaphb]

I use Doxycycline for Lymes and it is a 30-60 day course. No effect on her pain, but it cleared up her acne. Only 4/10 IGG's positive on testing.😀

Maybe our training was a little different...

As far as testosterone replacement for opioid induced hypogonadism (257.2)- that is creating a problem and punting. I am quite comfortable with all of my adjuncts. I do not manage any patients chronic disease not directly related or with close proximty to their pain. I do not read EKG's, CXR's, or play around with HTN, BPH, DM, CAD, Chol, etc.

Frankly I am disappointed in the acusatory nature of the thread especially when mentioning "scope" issues. It may be better to ask, "What training have you had?", "What kind of informed consent do you give when offering testing and medications for conditions like thyroiditis, autoimmune disorder NOS, etc?"

Have you ever written for plaquenil? Why not? When the rheum kicks them to you with an ESR=60, ANA neg, and a RF + but with the wrong titer numbers, do you reach for a bottle of Lortab/Celebrex and say thats all I got? Because I provide advice to the patient that there is more out there. We may trial Medrol, Plaquenil (remember to send them to Optho), and a new rheum to assist.

Nope, no African Sleepers. Had a case of Chagas- but the ID guys took care of that. I do find many interesting things in my patients- but only because I am looking really hard. I like it as much as they do, even if we have no cure or good treatment- sometimes its validation that makes them fel better.

Where do we want to draw the line on RX? None, Opioids, SMR's, NSAIDs, Steroids, AED's, SSRI, SNRI, BZD's, Sleep agents, ABX post procedure (be wary of Cipro if they are on Zanaflex (absolute contraindication)?

I'm not a cowboy or a pioneer, and I know when to punt. /rant off/

WRITING for plaquenil, testosterone, armour thyroid or doxycycline is beyond my personal scope. I prefer to talk about these options, and then make treatment recommendations, both to the patient and the referral source. In my population, the patient's remain appreciative, and the consultants they take these suggestions to remain the ultimate "experts" (at least in their own minds)