You are here

  • Home
  • Archive
  • Volume 5, Issue 3
  • A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota

Article Text

Article menu

Download PDFPDF

XML
Rheumatology
Research
A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota
  1. Ann Vincent1,
  2. Mary O Whipple1,
  3. Samantha J McAllister1,
  4. Katherine M Aleman1,
  5. Jennifer L St Sauver2
  1. 1Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Ann Vincent; vincent.ann{at}mayo.edu

Abstract

Objectives The objective of this study was to evaluate the problem of multiple chronic conditions and polypharmacy in patients with fibromyalgia.

Design Retrospective medical record review.

Setting Olmsted County, Minnesota.

Participants 1111 adults with fibromyalgia.

Primary and secondary outcome measures Number and type of chronic medical and psychiatric conditions, medication use.

Results Medical record review demonstrated that greater than 50% of the sample had seven or more chronic conditions. Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia. Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by selective serotonin reuptake inhibitors (28.7%), opioids (22.4%) and serotonin norepinephrine reuptake inhibitors (21.0%).

Conclusions The results of our study highlight the problem of multiple chronic conditions and high prevalence of polypharmacy in fibromyalgia. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications.

  • EPIDEMIOLOGY
  • INTERNAL MEDICINE

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2014-006681

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Strengths and limitations of this study

    • This is the first study to evaluate the presence of multiple chronic conditions in a large sample of community-dwelling adults with fibromyalgia.

    • Notably, greater than 50% of our sample had seven or more chronic conditions.

    • Given this was a community-sample in Olmsted County, Minnesota, the results of our study may not be generalisable to other samples of patients.

    • Additionally, we did not include all possible medical and psychiatric conditions in this study.

    • The results of our study highlight the problem of multiple chronic conditions in fibromyalgia and indicate that clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions.

    Introduction

    The presence of multiple chronic conditions is increasingly recognised as a challenge in the medical management of patients with chronic diseases including diabetes, heart disease, obesity and arthritis.1 ,2 Although most healthcare systems are excellent at managing individual conditions, these systems are often ineffective in caring for patients with multiple chronic conditions. This is because the care of patients with multiple chronic conditions must simultaneously consider the inter-relationship of different conditions and the implication of medication choice on the patient's other conditions. This complicates medical evaluation, decision-making and management.3 ,4 For example, the use of steroids to treat polymyalgia rheumatica in a patient who also has type II diabetes, hypertension and obesity requires more complex decision-making than is guided by singular protocols that are currently in use. A situation such as this is a common observation in clinical practice and is problematic as the percentage of patients with multiple chronic conditions is steadily increasing.5

    Fibromyalgia is a chronic condition that is relatively common in clinical practice6 ,7 and is associated with multiple chronic medical and psychiatric conditions. A small body of literature has reported a high prevalence of headaches, irritable bowel syndrome, chronic fatigue, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, sleep disorders, hypertension, type II diabetes, depression and anxiety8–12 in fibromyalgia, but the majority of these papers focused on either medical or psychiatric conditions and/or disability. Furthermore, no publications to date have considered the cumulative burden of multiple chronic conditions in fibromyalgia. This is important because not only is fibromyalgia difficult to manage, but fibromyalgia in combination with other chronic medical and psychiatric conditions substantially amplifies a patient's symptom burden and complicates the medical management for healthcare providers. This is further complicated by the use of multiple medications (with multiple side effects) to manage pain and other symptoms in fibromyalgia, as many of the medications employed frequently contribute to or exacerbate existing comorbidities.13–15

    Recognising the presence of multiple chronic conditions and the potential for polypharmacy may be one step towards improving the current, ineffective management of fibromyalgia. The objective of this report is to describe the proportion of patients with multiple chronic conditions and the proportion of patients using multiple medications related to fibromyalgia, in a cohort of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota.

    Materials and methods

    This cross-sectional study utilised a sample of patients identified via the Rochester Epidemiology Project (REP) and previously described.7 On identification of eligible patients, detailed medical record review was conducted to assess the presence of medical and psychiatric conditions as outlined below.

    The REP

    The REP is a unique resource that indexes the medical records of all residents who receive care in Olmsted County, Minnesota. In Olmsted County, all medical care is provided by two medical facilities: Mayo Clinic and Olmsted Medical Center. Each institution uses a unit (or dossier) medical record system, whereby data from an individual (eg, demographics, diagnoses and billing records) are assembled in one place and are made available for approved research studies under the umbrella of the REP.16 ,17 The majority of residents receive care at more than one institution, resulting in multiple records to be reviewed for each person. The REP maintains an index of the diagnostic codes obtained from all of the participating providers. The REP diagnostic index includes diagnostic codes from the International Classification of Diseases (HICDA) for conditions identified by physicians during office visits or hospital stays. This index can be searched to identify groups of patients with a particular condition of interest in the Olmsted County population. This is a unique resource that captures virtually the entire Olmsted County population18 and allows for comprehensive medical record review.

    Participants and procedure

    In this study, we utilised the REP to identify patients with fibromyalgia. To do so, we used the REP diagnostic index to retrieve a list of all Olmsted County residents aged 21 years and older who had received a diagnosis of fibromyalgia (HICDA code 07893-21-3 or ICD-9 code 729.1 (myalgia, myositis, fibromyositis, or fibromyalgia)) between 1 January 2005 and 31 December 2009. Since these codes are not specific to fibromyalgia and include other diagnoses such as myalgia and myositis, individual medical records of all of the patients retrieved in this search were reviewed to confirm a diagnosis of fibromyalgia by a healthcare provider. Of the 3410 patients identified, 86 declined authorisation for medical record review. Medical records were reviewed to evaluate the presence of a number of medical and psychiatric comorbidities most commonly reported in patients with fibromyalgia.8–12 These included degenerative joint disease/arthritis, rheumatoid arthritis, systemic lupus erythematosus, plantar fasciitis, migraines/chronic headaches, temporomandibular joint disorder, chronic pelvic pain, endometriosis, irritable bowel, irritable bladder, anxiety, depression, dysthymia, bipolar disorder, insomnia, restless legs syndrome and metabolic syndrome. Given the retrospective nature of this study and the limited variables available to define metabolic syndrome, for the purpose of this study, metabolic syndrome was defined as the presence of two of more of the following: body mass index (BMI) greater than 30, diabetes mellitus type II, hypertension and hyperlipidaemia. Information regarding use of medications related to fibromyalgia was also abstracted as of the reference date (31 December 2012). These included serotonin norepinephrine reuptake inhibitors (SNRIs), α-2-δ ligands, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), opioids, tramadol, skeletal muscle relaxants, benzodiazepines, sleep aids and other psychiatric medications. Sleep aids included zolpidem, zaleplon, eszopiclone, trazodone and melatonin. Other psychiatric medications included lithium, monoamine oxidase inhibitors, antipsychotics, bupropion, lamotrigine and tetracyclic antidepressants.

    Statistical analysis

    Descriptive statistics were calculated from demographic variables and recorded as means and SDs. The total number of patients with each chronic condition was determined and reported as per cent of the total sample. Similarly, the use of medications in each class as documented in the medical record was reported as per cent of the total sample. In order to determine the number of patients with multiple conditions, a total number of chronic conditions was determined for each patient. This process was repeated with medications.

    All participants provided consent for use of their medical records for research.

    Results

    A total of 1111 patients had a diagnosis of fibromyalgia confirmed via medical record review. Patients in this cohort had a mean age of 59.4 (SD 14.2) and a mean BMI of 30.8 (SD 7.7). As expected based on the prevalence of fibromyalgia in the general population,6 ,7 the majority of our sample was female (93.7%). The average duration of fibromyalgia, based on the date diagnosis first appeared in the medical record, was 11.1 years (SD 6.0).

    Greater than 50% of the sample had seven or more chronic conditions (figure 1A). Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Of the sample, 50.5% met criteria for metabolic syndrome. A list of all medical and psychiatric conditions abstracted is reported in table 1.

    View this table:
    Table 1

    Co-occurring medical conditions and prescription medications among fibromyalgia patients

    Figure 1
    Figure 1

    Pie charts demonstrating the percentage of patients with fibromyalgia who have multiple comorbidities (panel A) and the percentage of patients who are taking multiple medications (panel B).

    Medication use is also reported in table 1. Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia (figure 1B). Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by SSRIs (28.7%), opioids (22.4%) and SNRIs (21.0%). Overall, 31.4% of our sample was taking either tramadol or an opioid.

    We also evaluated conditions that co-occurred most frequently and medications that were used most frequently together, as reported in table 2.

    View this table:
    Table 2

    Most common combinations of conditions and medications in patients with fibromyalgia

    The conditions that most commonly occurred together were chronic joint pain/degenerative arthritis and depression (67.4%), followed by chronic joint pain/degenerative arthritis and migraines/chronic headaches (56.5%), and chronic joint pain/degenerative arthritis and anxiety (51.2%). The medications that were used most frequently together were sleep aids and SSRIs (11.7%), sleep aids and opioids (9.3%), and sleep aids and other psychiatric medications (9.1%).

    Discussion

    The results of our study highlight the problem of multiple chronic conditions in fibromyalgia. Notably, greater than 50% of our sample had seven or more chronic conditions and the most frequent of those were other pain disorders (chronic joint pain/degenerative arthritis and migraines/chronic headaches), depression and anxiety. Given that the presence of unrefreshing sleep is included in the 2010 fibromyalgia diagnostic criteria,19 it was not surprising that a high percentage (over 50%) of our sample had a diagnosis of insomnia. While a high prevalence of obesity in fibromyalgia has been previously reported20–22 and is present in our sample, we did not expect to observe so many cases of hypertension, hyperlipidaemia and diabetes mellitus that resulted in over 50% of our sample meeting criteria for metabolic syndrome. Our results add to the growing body of evidence regarding the importance of considering the cumulative burden of multiple chronic conditions in fibromyalgia.

    The presence of other pain conditions and anxiety and depressive disorders can contribute to the overall symptom burden in individual patients with fibromyalgia. Having fibromyalgia, in itself, is challenging for patients, due to the lack of effective management modalities. When this problem is exacerbated by the presence of other pain disorders, the burden of pain to a patient with fibromyalgia is increased. Further complicating this is the high prevalence of depression and anxiety in fibromyalgia, which can amplify fibromyalgia symptoms and make it difficult to sort out causal relationships. For example, in order to effectively manage insomnia, it would be useful to determine whether the insomnia results from depression or sleep disturbance from pain. If clinical management of fibromyalgia is to be most effective, evaluations should also take into consideration the assessment and management of multiple chronic conditions that also influence a patient's overall symptom burden.

    Another important finding in our study was the high prevalence of the use of multiple medications in fibromyalgia. Although pain, anxiety and depression were the most common chronic conditions, sleep aids were the most commonly prescribed medications in our sample. This may be reflective of the bidirectional relationship of sleep with pain, anxiety and depression. Additionally, greater than 40% of the sample were prescribed three or more medications for fibromyalgia management, and interestingly, greater than 10% were prescribed five or more medications for symptom management. This is concerning in that although these medications may have therapeutic effects, the side effects of these medications could contribute to worsening comorbidity. For example, SNRIs that are Food and Drug Administration (FDA) approved for fibromyalgia have both weight gain and increased blood pressure as side effects.13 ,15 Although the use of these medications to lower pain and improve mood in fibromyalgia may be appropriate, their use could exacerbate other chronic conditions such as hypertension and obesity. Also, increased weight, through its physical effects on joints, could worsen chronic joint pain/degenerative arthritis. Interestingly, a large percentage of patients were using opioids (22.4%), despite the lack of definitive data supporting their use in fibromyalgia. This indicates the challenge of effectively managing chronic pain in this population. A large percentage of patients were also using benzodiazepines (19.3%), although it was unclear whether they were prescribed for anxiety, sleep or both. The use of sedating medications such as opioids and benzodiazepines in patients with fibromyalgia with sleep disorders (eg, sleep disordered breathing) could be problematic. Therefore, the influence of multiple medications on a patient's multiple chronic conditions should be considered prior to prescribing.

    A recent paper by Rocca et al23 provides estimates of the prevalence of five of the chronic conditions also assessed in our study in general population of Olmsted County. Among those aged 50–69 years in the general population, the prevalence of arthritis, hyperlipidaemia, hypertension, diabetes and depression was 13.2–22.2%, 33.2–50.6%, 23.8–42.9%, 15.9–26.6% and 12.0–14.5%, respectively. Except for diabetes, these conditions appear to be more common in our sample of patients with fibromyalgia.

    This study was unique in that use of the REP allowed us conduct exhaustive medical record review in a large sample of community-dwelling adults with fibromyalgia. However, the results of our study may not be generalisable to other samples of patients with very different characteristics. Additionally, as we were primarily interested in evaluating the presence of chronic medical conditions that were commonly observed in the clinical care of patients with fibromyalgia, we did not include all possible medical and psychiatric conditions in this study. Another limitation is that 86 of the 3410 patients originally identified did not provide authorisation for researchers to use their medical records, and therefore could not be included in the medical record review, which is a potential source of bias. Despite these potential limitations, this report of multiple chronic conditions and medication use in a community-dwelling sample of patients with fibromyalgia adds substantially to the literature.

    To conclude, multiple chronic conditions and the use of multiple medications are highly prevalent in patients with fibromyalgia and pose a unique challenge to the management of this condition. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications. Furthermore, properly addressing these multiple chronic conditions may mitigate the patient's overall illness burden.

    Acknowledgments

    Study data were collected and managed using REDCap electronic data capture tools hosted at Mayo Clinic. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.

    References

    1. ↵
      1. Grembowski D,
      2. Schaefer J,
      3. Johnson KE, et al
      . A conceptual model of the role of complexity in the care of patients with multiple chronic conditions. Med Care 2014;52(Suppl 3):S7–S14. doi:10.1097/MLR.0000000000000045
      OpenUrl
    2. ↵
      1. Leroy L,
      2. Bayliss E,
      3. Domino M, et al
      . The Agency for Healthcare Research and Quality Multiple Chronic Conditions Research Network: overview of research contributions and future priorities. Med Care 2014;52(Suppl 3):S15–22. doi:10.1097/MLR.0000000000000095
      OpenUrlCrossRefPubMedWeb of Science
    3. ↵
      1. Tinetti ME,
      2. Basu J
      . Research on multiple chronic conditions: where we are and where we need to go. Med Care 2014;52(Suppl 3):S3–6. doi:10.1097/MLR.0000000000000093
      OpenUrl
    4. ↵
      1. Wyatt KD,
      2. Stuart LM,
      3. Brito JP, et al
      . Out of context: clinical practice guidelines and patients with multiple chronic conditions: a systematic review. Med Care 2014;52(Suppl 3):S92–S100. doi:10.1097/MLR.0b013e3182a51b3d
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      Partnership for Solutions. Chronic conditions: making the case for ongoing care. Johns Hopkins University, 2004.
    6. ↵
      1. Wolfe F,
      2. Ross K,
      3. Anderson J, et al
      . The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995;38:19–28. doi:10.1002/art.1780380104
      OpenUrlCrossRefPubMedWeb of Science
    7. ↵
      1. Vincent A,
      2. Lahr BD,
      3. Wolfe F, et al
      . Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res 2013;65:786–92. doi:10.1002/acr.21896
      OpenUrlCrossRefWeb of Science
    8. ↵
      1. Arnold LM,
      2. Hudson JI,
      3. Keck PE, et al
      . Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry 2006;67:1219–25. doi:10.4088/JCP.v67n0807
      OpenUrlPubMedWeb of Science
    9. ↵
      1. Buskila D,
      2. Cohen H
      . Comorbidity of fibromyalgia and psychiatric disorders. Curr Pain Headache Rep 2007;11:333–8. doi:10.1007/s11916-007-0214-4
      OpenUrlCrossRefPubMed
    10. ↵
      1. Przekop P,
      2. Haviland MG,
      3. Zhao Y, et al
      . Self-reported physical health, mental health, and comorbid diseases among women with irritable bowel syndrome, fibromyalgia, or both compared with healthy control respondents. J Am Osteopath Assoc 2012;112:726–35.
      OpenUrlPubMed
    11. ↵
      1. Weir PT,
      2. Harlan GA,
      3. Nkoy FL, et al
      . The incidence of fibromyalgia and its associated comorbidities: a population-based retrospective cohort study based on International Classification of Diseases, 9th revision codes. J Clin Rheumatol 2006;12:124–8. doi:10.1097/01.rhu.0000221817.46231.18
      OpenUrlCrossRefPubMedWeb of Science
    12. ↵
      1. White LA,
      2. Birnbaum HG,
      3. Kaltenboeck A, et al
      . Employees with fibromyalgia: medical comorbidity, healthcare costs, and work loss. J Occup Environ Med 2008;50:13–24. doi:10.1097/JOM.0b013e31815cff4b
      OpenUrlCrossRefPubMed
    13. ↵
      Forest Pharmaceuticals, Inc. Savella (milnacipran hydrochloride) tablets [prescribing information]. St Louis, MO: Forest Pharmaceuticals, 2009.
    14. ↵
      Pfizer, Inc. Lyrica (pregabalin) capusules [prescribing information]. New York, NY: Pfizer, Inc, 2009.
    15. ↵
      Eli Lilly and Company. Cymbalta (duloxetine hydrochloride) delayed release capsules [prescribing information]. Indianapolis, IN: Eli Lilly and Company, 2008.
    16. ↵
      1. Rocca WA,
      2. Yawn BP,
      3. St Sauver JL, et al
      . History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population. Mayo Clin Proc 2012;87:1202–13. doi:10.1016/j.mayocp.2012.08.012
      OpenUrlCrossRefPubMedWeb of Science
    17. ↵
      1. St Sauver JL,
      2. Grossardt BR,
      3. Yawn BP, et al
      . Data resource profile: the Rochester Epidemiology Project (REP) medical records-linkage system. Int J Epidemiol 2012;41:1614–24. doi:10.1093/ije/dys195
      OpenUrlAbstract/FREE Full Text
    18. ↵
      1. St Sauver JL,
      2. Grossardt BR,
      3. Yawn BP, et al
      . Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester Epidemiology Project. Am J Epidemiol 2011;173:1059–68. doi:10.1093/aje/kwq482
      OpenUrlAbstract/FREE Full Text
    19. ↵
      1. Wolfe F,
      2. Clauw DJ,
      3. Fitzcharles MA, et al
      . Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011;38:1113–22. doi:10.3899/jrheum.100594
      OpenUrlAbstract/FREE Full Text
    20. ↵
      1. Okifuji A,
      2. Donaldson GW,
      3. Barck L, et al
      . Relationship between fibromyalgia and obesity in pain, function, mood, and sleep. J Pain 2010;11:1329–37. doi:10.1016/j.jpain.2010.03.006
      OpenUrlCrossRefPubMedWeb of Science
    21. ↵
      1. Ursini F,
      2. Naty S,
      3. Grembiale RD
      . Fibromyalgia and obesity: the hidden link. Rheumatol Int 2011;31:1403–8. doi:10.1007/s00296-011-1885-z
      OpenUrlCrossRefPubMed
    22. ↵
      1. Yunus MB,
      2. Arslan S,
      3. Aldag JC
      . Relationship between body mass index and fibromyalgia features. Scand J Rheumatol 2002;31:27–31. doi:10.1080/030097402317255336
      OpenUrlCrossRefPubMedWeb of Science
    23. ↵
      1. Rocca WA,
      2. Boyd CM,
      3. Grossardt BR, et al
      . Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity. Mayo Clin Proc 2014;89:1336–49. doi:10.1016/j.mayocp.2014.07.010
      OpenUrlPubMedWeb of Science

    Footnotes

    • Contributors AV, MOW and JLSS were involved in conception and design. AV, MOW, SJM, KMA and JLSS were involved in acquisition, analysis or interpretation of data, and drafting the work or revising it critically for important intellectual content, and final approval of the version to be published. AV, MOW, SJM, KMA and JLSS were in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding This study was made possible using the resources of the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG034676.

    • Competing interests None.

    • Ethics approval Mayo Clinic Institutional Review Board.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.