Overlap of Fibromyalgia and IBS
Fibromyalgia (FM) is a condition marked by muscle pain all over the body, sleep problems, and fatigue. FM is often accompanied by emotional and mental distress and affects about 4 million U.S. adults, or about 2% of the adult population.
We do not know what specifically causes IBS and FM to occur in the same person. Due to the overlap of symptoms, treatment may be similar. Drugs and other therapies used for IBS and FM are common for both conditions.
Treatments will vary from patient to patient because of the diverse range of symptoms shown in both IBS and FM. Researchers are trying to find out why FM and IBS seem to be linked. FM is the most studied condition that occurs with IBS since there are many people diagnosed with both. About 33% of people diagnosed with IBS are later diagnosed with FM. About 48% of people diagnosed with FM are later diagnosed with IBS. FM tends to occur later in life whereas most patients with IBS are diagnosed in their 20’s or 30’s.
IBS and FM can both have a large, negative impact on activities of daily living, and overall quality of life. In addition, they can lead to increased health care costs
FM and IBS overlap in both treatments and many pain related symptoms. Some research studies suggest that IBS and FM may have the same cause. Changes in any or all of the following may be the source.
- The central nervous system (CNS): The CNS includes the brain, spinal cord, and nerves. There could be changes in how the CNS communicates with the rest of the body.
- Immune system: The immune system is the body’s tool for preventing or limiting infection. Changes to the immune system may affect the body’s ability to fight off foreign and harmful invaders like bacteria, viruses, fungi, and toxins.
- Psychosocial factors: This involves the relationship between thoughts, behaviors, and social factors. These factors can have a negative impact and impair quality of life.
Severity of Symptoms
The severity of IBS and FM can be associated with many factors:
- intensity of GI symptoms symptoms in the belly that occur outside the intestines
- psychosocial factors such as stress, anxiety, and depression
- any limit to physical movement
- an urgent need to go to the bathroom
- migraine headaches
Patients with mild to moderate IBS and FM are more likely to have symptoms that are:
- related to bowel movements
- worsen with eating
- irregular, crampy abdominal pain
- nausea soon after meals
- leakage of stool
The severity of symptoms above can predict quality of life impairments such as mental and physical wellbeing and their social interactions.
Treatments of Fibromyalgia and IBS Occurring Together
Your healthcare provider should educate you about the similarities of the two conditions and come up with goals for your care. Patients benefit most from a multidisciplinary treatment that combines traditional drugs with complementary techniques such as exercise, diet changes and psychological support. This type of treatment is tailored to each person’s needs and symptoms. The most studied alternate therapies include exercise, patient education, and cognitive behavioral therapy (CBT). Exercise therapy and CBT both show benefits when used together in patients with FM and IBS.
Improved physical fitness with both cardiovascular and strength training is the best option. This can reduce pain, improve quality of life, and decrease symptom severity, fatigue and depression. Exercise has also been shown to improve GI motility as well, further benefiting IBS patients.
Traditional exercises such as cycling, walking, swimming, and jogging can show benefits. Alternative exercise options such as tai chi and yoga can also be helpful. In fact, studies have shown improvements in many IBS symptoms after yoga.
Heated pool treatments, relaxation, and deep tissue massage have been effective in improving pain and function. Maintaining an exercise program and physical activity is vital to symptom improvement. Gradually increasing the intensity of your exercise is also an important consideration. Most patients want to maintain moderate exercise once they have worked up to that level.
The most effective, dietary treatment for IBS is the low fermentable oligosaccharides, disachrides, monosaccharides and polyol (FODMAP) diet. This is an elimination diet that helps find foods – mostly carbohydrates- that cause symptoms of bloating, distension, pain, and bowel habit changes. This includes fructose, fructans, galactooligosaccharides, lactose, and polyols. The low FODMAP diet can be effective for many patients with IBS; however, studies have not been done in FM.
Determining which of the 5 food types worsen your GI symptoms helps to improve health and quality of life. For this method, all 5 types of food are removed from the diet. Each of the groups is brought back into the diet one at a time. This allows people to find what foods may cause specific symptoms. Gluten-free diets were previously recommended for treating IBS-D in people who suspected a gluten sensitivity. New research has shown this is not as effective of a treatment. For any diet changes and dietary treatment options, it is best to work with a registered dietitian.
As part of the multidisciplinary approach to these disorders, CBT, mindfulness-based treatments and hypnotherapy may be useful. These treatments may improve pain, help to gain coping strategies, and improve overall physical function in some people. This has been found to be effective in short term relief of pain.
The most studied psychological treatment for IBS and Fibromyalgia is cognitive behavioral therapy (CBT). CBT is a type of psychological treatment that works to change thought patterns. The development of positive thought patterns and habits has been found to improve pain and other negative symptoms. The idea of CBT is that negative thoughts and responses create emotions that negatively affect the body. This impacts behavior, emotions, and the body’s nerve responses. The goal of CBT is to help patients better understand and improve their thought patterns.
Medications for Irritable Bowel Syndrome and Fibromyalgia
Drugs to treat IBS and FM should correct the nerve pain that occurs as a result of the nerves being more sensitive to any pain and distension. Distension occurs with an uncomfortable swelling in the intestines where the abdominal area visibly expands. Nerves that do not signal at the proper rate will cause issues throughout the body and either produce too much or too little of the neurotransmitters needed for the gut to function properly.
Neurotransmitters are the chemicals in the body that regulate nerve signaling. Each chemical has a specific purpose. In IBS and FM, the amount of chemicals that signal for feeling pain are either too high or too low. One example is serotonin, a chemical involved in nerve impulses that aid in digestion. Some people with IBS-D have levels of serotonin that are too high, leading to increased diarrhea. Some with IBS-C have levels of serotonin that are too low, leading to increased constipation.
Listed below are drugs commonly used, but not approved by the FDA, for use with IBS. The most frequently prescribed medications for both conditions are:
- Tricyclic antidepressants (TCAs) – TCA’s increase the amount of serotonin and norepinephrine. These are both chemicals that are involved in nerve impulses. They work by preventing nerves from using those chemicals. The result is a decrease in pain, or awareness of that pain. TCA’s can be helpful in both treatment of FM and IBS. TCAs such as amitriptyline with nortriptyline have shown to be the most effective in FM.
- Antispasmodics – Antispasmodics are drugs which limit smooth muscle contractions in the GI tract. Smooth muscles are located throughout the body and contract, or put pressure on, internal organs and blood vessels. There are three major classes of antispasmodics:
- Anticholinergics – These drugs reduce spasms or contractions in the intestines. The most common anticholinergics include hyoscyamine (Levsin®, NuLev®, Levbid®) and dicyclomine (Bentyl®).
- Direct Smooth Muscle Relaxants – Smooth muscle relaxants are not currently available for use in the United States. These drugs appear more effective for treating overall IBS symptoms than the anticholinergics.
- Peppermint Oil – Peppermint oil causes smooth muscle relaxation by blocking calcium entry into intestinal smooth muscle cells. Calcium triggers muscle contraction, so the lack of calcium results in relaxing intestinal muscles. It also has anti-inflammatory, anti-gas, and anti-serotonergic properties. Serotonin is a chemical found in the gut that accelerates movement. Examples of this medication include Pepogest ® and IBGard ®.
- Selective serotonin and norepinephrine reuptake inhibitors (SSRIs and SNRIs) – These include fluoxetine, duloxetine, and milnacipran. They are used for patients with both FM and IBS. Some studies have shown benefit in improving pain and function. In some patients with IBS-C these drugs can also help with constipation. Studies show that SSRIs and SNRIs may be best for patients who have FM, IBS, and anxiety and/or depression.
- Gabapentin – This is an anticonvulsive medication that is used to treat seizures. It has been found to help reduce pain in some patients that have FM and IBS. Careful dosing should be done with this medication as many side effects can limit its use for all people.
- Pregabalin – This is a drug that increases the amount of a specific neurotransmitter outside of cells. Some evidence shows that this drug helps reduce pain sensitivity, sleep issues, and fatigue for those with FM. In IBS this can reduce pain sensitivity, bloating, and diarrhea without significant side effects.
These medications have been studied and can reduce pain, fatigue, and insomnia, and improve overall health. In addition to helping the central nervous system, antidepressants can help GI symptoms. These drugs can either reduce or improve contractions and spasms in the intestines. This action can then regulate GI motility, the movement of food and liquids through the GI tract. The only drugs of this type that are approved by the FDA for FM are duloxetine, milnacipran, and pregabalin. None of these medications are currently approved for IBS.
Overlap of Fibromyalgia (FM) and GI Conditions
GI conditions and symptoms often occur with FM. FM has been linked to the following GI conditions:
- IBS – A common GI condition marked by abdominal pain and/or discomfort. Patients often have a change in bowel habits that cannot be explained by other tests or diagnoses.
- Gastroesophageal reflux disease (GERD) – A common GI condition where patients feel burning in their chest and throat. This burning occurs in the esophagus, a muscular tube that connects the mouth and stomach. This results from acid that enters the esophagus from the stomach region. Patients refer to this as heartburn and oftentimes also regurgitate or bring up their food or acidic contents from the stomach.
- Functional dyspepsia – A condition with discomfort or pain in the upper abdomen. This area includes the stomach or small intestine. Symptoms include burning or pain in the upper abdomen, early fullness, bloating, nausea, and rarely vomiting. Some causes of dyspepsia can be stress or excess acid production, but many other causes are unknown.
Adapted from IFFGD Publication #149 Fibromyalgia and IBS By: Baharak Moshiree MD MSc, Mackenzie Jarvis PA-C, DMs, Atrium Health, Wake Forest, Digestive Health-Morehead Medical Plaza; Marissa Lombardi, Program Coordinator, IFFGD