Botox Injections for Fibromyalgia?

Q:  Have you heard of Botox injections for fibromyalgia? If so, what are they and how do they work?

A:  ABotulinum toxin type A (Botox) is produced by a bacterium called clostridium botulinum. The U.S. military originally purified the toxin about 30 years ago as a potential nerve agent. More recently, the toxin, which blocks neuromuscular transmission, has been used for medicinal purposes.

When injected in small quantities, Botox causes selective weakening and paralysis of muscles, thereby alleviating spasms and pain. Although the drug is approved only for certain problems involving the muscles of the eyes, doctors have used it to treat the muscular rigidity seen in various medical conditions including cerebral palsy, strokes, multiple sclerosis and some esophageal disorders, and for the pain of a muscular condition called myofascial pain syndrome. In fact, it was the successful use of Botox in some people with severe myofascial pain syndrome that led doctors to try it for fibromyalgia.

Although its use in fibromyalgia is not well studied, it is being pushed over the Internet and in the news media as the new “miracle cure” for fibromyalgia. There are reports of patients with fibromyalgia getting some relief of their tender points (from injections) that lasts up to three to four months. Even though muscle pain is one of the major features of fibromyalgia, there are many other symptoms of the condition not helped by Botox.

If you decide to try Botox, be prepared to wait about eight days before you see any effects. The most relief occurs at about three weeks, and the injections can be repeated every three to four months. But be careful not to get them more often. Too frequent injections may cause you to develop immunity to the injections. Some patients who have received too much Botox, depending on the location of the injections, have developed facial and eyelid drooping, bruising, jaw weakness, headache, neck or back pain, and back weakness. Such symptoms last until the injections wear off.

When administered correctly, Botox appears to be safe. But the drug is expensive, costing $400 per injection.

JAMES MCKOY, MD
Rheumatologist

CAUSE OF SHOCKING LEG PAIN
Q. I have spinal stenosis and for about two years I have experienced twinges like small electric shocks in my legs below the knee. These occur about twice a month at night while I sleep. They are severe enough to awaken me and keep me awake. Can you explain why this happens and what I can do for them?

A. Spinal stenosis is a condition in which the spinal column narrows, often because of the bony overgrowth associated with osteoarthritis. In some cases, this causes the nerves of the legs to be pinched and become irritated. You may feel that as small shocks.

I suspect that you experience them at night because when you lie down, you can change the curvature of your back enough to shift the bones a millimeter or two, which is all it takes to pinch the nerve. If your mattress is old (more than 10 years), it may be too soft and thus allow your spine to curve too much.

As far as what you can do, you might try experimenting with a harder or softer mattress to see if that helps. You may start by placing a sheet of plywood under your own mattress to make it harder or try another bed in the house.

Since your problem is intermittent, it might take a while to figure out what helps, so don't rush out to buy an expensive new mattress unless you are convinced it makes a difference. You may also want to talk to your doctor about whether your spinal stenosis is severe enough to warrant surgery, which may involve removing some of the debris that is pressing on the nerves.

RONENN ROUBENOUFF, MD, MHS
Rheumatologist

X-RAYS AFTER JOINT REPLACEMENT
Q. I had hip replacement surgery earlier this year. My physician has already ordered several follow-up X-rays and has told me I'll need X-rays annually. I am concerned about excessive X-ray exposure – are all of these X-rays really necessary?

A. Yes, follow-up X-rays are always necessary for people who have undergone hip replacements, but just how often you need them will be determined by your doctor based on your risk of complications. Risk factors for complications include excess weight, osteoporosis and previous hip surgery.

In most cases, one or two X-rays are needed immediately after surgery to document the position and alignment of the prosthesis. Then, in the first few months following joint replacement, surgeons take X-rays to document the bony ingrowth around noncemented prostheses.

In the years afterward, a surgeon will order additional X-rays to check for and document the degree of wear, loosening or migration of the joint components. Excessive wear, loosening or large bone cyst formation can cause pain and lead to the need for hip revision surgery some years after the initial procedure. Your surgeon will be looking for bone erosions around the edge of the prosthesis and will give you a report after each X-ray.

Patients at high risk for complications may require X-rays yearly or more frequently for monitoring. Patients who have undergone a second hip replacement on the same hip will need more careful monitoring than someone who has had only one joint replacement, because second surgeries tend to be more complicated than the first.

After their two-year visit, I usually ask my low-risk hip replacement patients to return for pelvic X-rays once every two years thereafter, as long as they are not having unusual pain in the replaced hip. Anyone who develops increased pain should come back for an X-ray as soon as possible.

Because you are understandably concerned about X-ray exposure, I recommend you speak with your physician about limiting your X-rays to the least possible. Also, you may want to request a gonad shield (a shield that protects your reproductive organs from radiation) when undergoing pelvic X-rays.

Ultimately, you and your physician must balance the risk of radiation exposure with the benefit of knowing the condition and position of the prosthesis within the bone after joint replacement surgery.

JEFFREY T. NUGENT, MD
Orthopaedic Surgeon

CAN OSTEOPOROSIS AFFECT THE MOUTH?
Q. I was diagnosed with osteoporosis after my dentist discovered some loose teeth. I understand that osteoporosis can lead to fractures of the hip, wrist and spine, but what does it have to do with teeth? Will regular osteoporosis treatments help me keep my teeth?

A. It is not unusual for a dentist to make a diagnosis of osteoporosis. Osteoporosis is a disease characterized by low bone mass (thinning of the bone) and deterioration of bone tissue. Because bone loss is systemic (meaning it affects the entire body), the bone that anchors the teeth can be affected. In post-menopausal women, loss of bone mineral density has been shown in scientific studies to correlate significantly with loosening and loss of teeth. Other factors that can affect tooth loss include smoking and periodontal diseases.

The best way to prevent further osteoporosis-related problems – in your mouth or elsewhere – is to see your primary care doctor or rheumatologist for treatment. It is also important that you see your dentist on a regular basis and practice good dental hygiene.

DR. McCOY

COMMON CAUSES OF HEEL PAIN
Q. I have rheumatoid arthritis (RA) and have recently been experiencing pain on the bottom of my heels that makes walking difficult. Is this related to my RA?

A. It certainly could be. It is not unusual to have foot pain associated with rheumatoid arthritis; the joints of the feet are among those commonly affected by the disease. In most cases, however, RA affects the feet and toes, not the heels.

Heel pain can come about through many causes both related and unrelated to your RA. For example, RA inflammation in other joints of the feet may have led to structural changes in the foot or the pain of RA may have caused to you to change the way you walk, which has led to stress on the tendons of your heel. Other potential causes of your heel pain include bursitis, inflammation of the fluid-secreting sacs that help lubricate the joints, and thinning of the heel pad.

An evaluation by a rheumatologist, orthopedist or a podiatrist may help sort these problems out. Often a treatment as simple as custom-made inserts (orthotics) for your shoes may give gratifying relief.

LEONARD H. CALABRESE, DO
Rheumatologist

METHOTREXATE AND WEIGHT GAIN
Q. Can taking methotrexate cause weight gain?

A. No, methotrexate has not been associated with weight gain; however, another common arthritis medication, prednisone, does cause weight gain. If you are taking prednisone along with methotrexate, which isn't uncommon in people with rheumatoid arthritis, then prednisone may be the culprit.

DR. ROUBENOFF

DANGERS OF FORGETTING TO TAKE PREDNISONE
Q. I am on 20 milligrams (mg) of prednisone daily and occasionally forget to take it, which my doctor says can be dangerous. What are the risks of missing a few doses of prednisone?

A. One of the problems with glucocorticoid drugs like prednisone is that they suppress the secretion of your own adrenal hormones. Consequently, if you miss several doses of prednisone you can suffer symptoms of adrenal insufficiency like weakness, loss of appetite, nausea, low blood pressure and dizziness.

The likelihood that you would have these symptoms depends on how long you've taken prednisone and how high a dose you use. If you have taken 20 mg daily for less than a month, missing a few doses is unlikely to cause symptoms. On the other hand, if you have used 20 mg of prednisone for several months or years, you almost certainly would have problems after missing a few doses.

Regardless of how long you have been taking the medication or at what dose, it's important that you do whatever you can to remember to take your medication.

If you take a daily dose in the morning, for example, leaving your medication next to your toothbrush, your coffee maker or another place where you'll see it first thing may help you remember.

No one should ever stop taking prednisone without notifying their doctor and discussing the potential consequences.

DONALD R. MILLER, PharmD
Phramacist

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