Rev. Bras. Reumatol. vol.55 número1

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

ww w . r e u m a t o l o g i a . c o m . b r

Original

article

The

association

of

fibromyalgia

and

systemic

lupus

erythematosus

change

the

presentation

and

severity

of

both

diseases?

Ana

Luiza

P.

Kasemodel

de

Araújo,

Isabella

Cristina

Paliares,

Maria

Izabel

P.

Kasemodel

de

Araújo,

Neil

Ferreira

Novo,

Ricardo

Augusto

M.

Cadaval,

José

Eduardo

Martinez

HospitalComplexofSorocabaandPontifíciaUniversidadeCatólicadeSãoPaulo(PUC-SP),Sorocaba,SP,Brazil

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o

Articlehistory:

Received19August2013 Accepted26August2014

Availableonline28November2014

Keywords: Fibromyalgia

Systemiclupuserythematosus Clinicalactivity

Qualityoflife Association

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t

Introduction:Theassociationoffibromyalgia(FM)andsystemiclupuserythematosus(SLE) hasbeeninvestigated,withconflictingresultsregardingtheimpactofaconditiononthe other.

Objectives: TodeterminethefrequencyofFMinasampleofpatientswithSLEtreatedatthe HospitalComplexofSorocaba(CHS)andtheimpactofFMinSLEactivityandqualityoflife, aswellasofSLEinFM.

MaterialsandMethods:Descriptiveandcorrelationalstudy.PatientswhomettheAmerican CollegeofRheumatology(ACR)criteriaforSLEand/orFMwereincluded.Thetotalsample wasdividedintothreegroups:FM/SLE(patientswithassociationofSLEandFM),SLE(SLE patientsonly)andFM(FMpatientsonly).Thefollowingvariableswereused:Fibromyalgia ImpactQuestionnaire(FIQ),activityindexofSLE(SLEDAI),IndicesofDiagnosticCriteriafor Fibromyalgia2010(SSIendGPI)andSF-36.

Results:TheprevalenceofpatientswithFMamongSLEpatientswas12%.FIQshowedno differencebetweengroups,indicatingthatSLEdidnotaffecttheimpactcausedbyFMalone. ThepresenceofFMinSLEpatientsdidnotinfluencetheclinicalactivityofthisdisease.A strongimpactofFMonthequalityoflifeinpatientswithSLEwasobserved;theopposite wasnotobserved.

Conclusions: TheprevalenceofFMobservedinSLEpatientsis12%.ThepresenceofFM adverselyaffectsthequalityoflifeofpatientswithSLE.

©2014ElsevierEditoraLtda.Allrightsreserved.

∗ _{Correspondingauthor.}

E-mail:jemartinez@pucsp.br(J.E.Martinez).

http://dx.doi.org/10.1016/j.rbre.2014.08.003

A

associac¸ão

fibromialgia

e

lúpus

eritematoso

sistêmico

altera

a

apresentac¸ão

e

a

gravidade

de

ambas

as

doenc¸as?

Palavras-chave: Fibromialgia

Lúpuseritematososistêmico Atividadeclínica

Qualidadedevida Associac¸ão

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e

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u

m

o

Introduc¸ão: Aassociac¸ãodafibromialgia(FM)edelúpuseritematososistêmico(LES)tem sidoinvestigadacomresultadosconflitantesemrelac¸ãoaoimpactodeumacondic¸ãona outra.

Objetivos: DeterminarafrequênciadeFMemumaamostradepacientescomLESatendidos noConjuntoHospitalardeSorocaba(CHS)eoimpactodaFMnaatividadedoLESena qualidadedevida,bemcomodoLESnaFM.

Materialemétodos: Estudodescritivoetransversal.Incluíram-sepacientesquepreenchem oscritériosdeclassificac¸ãoparaLESe/oudeFMdoColégioAmericanodeReumatologia (ACR).Aamostratotalfoidivididaemtrêsgrupos:FM/LES(pacientescomassociac¸ãoLES eFM),LES(somentepacientescomLES)eFM(somentepacientescomFM).Asseguintes variáveisforamQuestionáriodeImpactodaFibromialgia(FIQ),ÍndicedeAtividadedoLúpus EritematosoSistêmico(Sledai),ÍndicesdosCritériosDiagnósticosdeFibromialgiade2010 (IGSEIDG)eoSF-36.

Resultados: AprevalênciadepacientescomFMentreospacientescomLESfoide12%.O FIQnãoapontoudiferenc¸aentreosgruposeindicouqueoLESnãointerferiunoimpacto causadopelaFMisoladamente.Apresenc¸adaFMempacientescomLESnãoinfluencioua atividadeclínicadessadoenc¸a.Observou-seumforteimpactodaFMnaqualidadedevida nospacientescomLESenãofoiobservadoocontrário.

Conclusões: AprevalênciadeFMobservadanospacientescomLESéde12%.Apresenc¸ade FMafetaadversamenteaqualidadedevidadospacientescomLES.

©2014ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Fibromyalgia(FM)isarheumaticconditionthathasasmain featuresadiffusechronic pain,hyperalgesiaand allodynia. Fatigue,sleepdisturbances,morningstiffness,headacheand paresthesiaaresymptomsoftenpresent.1_{Comorbiditieslike}

depression, anxiety, irritable bowel syndrome, myofascial painsyndromeand nonspecificurethralsyndromeare also associated.2

Thissyndrome,whoseetiologyandpathogenesishavenot beenfullyelucidatedyet,hasasitsmostimportant mecha-nismtheamplificationofthetransmissionofpainfulstimuli, withchangesintheperceptionofpain.1_{Animbalancein}

neu-rotransmitters involvedinthe physiology ofpain was also observed. Among other abnormalities, na increase of sub-stancePandnervegrowth factorinthecerebrospinal fluid (CSF)ofindividualswithfibromyalgiawasfound.3

Although few Brazilian epidemiological data have been published,somestudiesshowaprevalenceofabout2.5%in thegeneralpopulation;mostlytheyarewomenaged35–44 yearsold.4_{Themeanageofpatientsisaround29.8yearsold.}

Arelationshipwithlowfamilyincomewasalsonoted.5

Theclinical assessment can be done through scales of intensityofsymptoms,byspecificinstrumentstoassessthe diseaseliketheFibromyalgiaImpactQuestionnaire(FIQ),6_and

bygenericquestionnairesonqualityoflife.7

Systemiclupus erythematosus(SLE) isan inflammatory autoimmunediseaseinvolvingmultipleorgans,especiallythe skin,joints,kidneys,bloodvessels,heartandlungs.Itisarare

disease,withmorefrequentincidenceinyoungwomen,i.e.,in thereproductivephase,inaratioofninetotenwomentoone man,andwithitsprevalencerangingfrom14to50/100,000 inhabitants.8–12

SLE causes significant morbidity and mortality due to inflammatorydiseaseactivity,infectiousprocessessecondary to the disease-induced immunosuppression and its treat-ment,andtocardiovascularcomplications.13

The disease assessmentcan be madeby clinical obser-vation, laboratory tests and imaging studies ofthe organs involved,evidenceofinflammatoryactivity,evidencerelating toautoimmunity,specificquestionnairesfortheassessment ofdiseaseactivitysuchastheSystemicLupusErythematosus DiseaseActivityIndex(SLEDAI)14_{andgenericquestionnaires}

toassessqualityoflife.15

TheassociationofFMandSLEhasbeeninvestigatedby sev-eralauthors,withconflictingresultsregardingtheimpactofa conditionontheother.16–22_{Theprevalenceofaconcomitant}

associationbetweenthetwodiseasesisaround20%.16_Thus,

Materials

and

methods

Thisisadescriptivecross-sectionalstudyinvolvingpatients fromtheRheumatologyoutpatientclinic,SorocabaHospital Complex(CHS).FemalepatientswhomettheAmerican Col-legeofRheumatology(ACR)criteriaforSLEand/orFMwere included.23,24

The patients were assessed by a rheumatologist who checkedthefulfillmentofACRcriteria.Thetotalsamplewas dividedinto threegroups:FM/SLE(patientswithan associ-ation ofSLE and FM), SLE(SLE patients only) and FM (FM patientsonly).

Data were obtained from medical records and through interviewsconductedforthequestionnaires’administration, sincethemedicalrecordsofpatientswithSLEdidnotpresent specifictoolsforFM;andthemedicalrecordsofpatientswith FMhadnospecifictoolsforLES.Besidesthese,thefollowing datawereobtainedthroughquestionnaires:diseaseduration, clinicalactivityand severityofthedisease,andtheimpact onthepatients’qualityoflife.Theinstrumentsusedinthis assessmentaredescribedbelow.

Thenumber of patients in each group was determined bythenumber ofpatientswiththe associationofSLEand FM in the outpatient clinic of CHS. Twenty patients were selectedforeachgroup.Duringthestudy,patientswhowere losttofollow-upwiththerheumatologistforunknown rea-sonswereexcluded,aswellaspatientswhosedataontheir medicalrecordswereincompleteandpatientswhose ques-tionnaireswerenotfullyanswered.Therewasnorefusalby anypatienttoanswerthequestionnaires.Althoughthe num-berofsubjectsinthisresearchcanbeconsideredsmall,the study designaimedto showthe reality ofa particular ser-viceand,therefore,anumbercompatiblewiththesizeofthe outpatientclinicwherethestudywasconductedwasused. Despitetheexclusions, anumberof20foreachgroupwas reached.

The impact of SLE on FM was evaluated using FIQ,25

whichprovedtobeavalidandreliableinstrument to mea-surefunctionalcapacityandhealthstatusofthesepatients. FIQconsistsofquestionsthatevaluatethedifficultythatFM imposesonday-to-dayactivities,theoccupationalimpactand theintensityofthemainfeaturesofthesyndrome.TheFIQ totalscorerangesfrom 0to100,0beingthemilderimpact and100beingtheworstimpact.Thisisaspecificinstrument; therefore,itshouldonlybeusedingroupswithpatientswho meettheclassificationcriteriaforFMandnotintheSLE-only group.

SLEDAI16 _{wasusedtoevaluatethe activity indexofSLE}

andthe impactthatFMmay haveonthis condition,using clinical parameters present in SLE. SLEDAI is a scale that assesses24variablesassociatedwithSLEactivityandgrouped into nine systems, wherein the presence ofeach commit-mentreceivesdifferentweights;thus,weight8tolesionsof thecentralnervoussystemandvascularinjuries;weight4for renal,musculoskeletalandosteoarticulardisorders;weight2 forskin,serousandimmunologicalchanges;andweight1for constitutionalandhematologicalsymptoms.Thescoreswere obtainedfromthemedicalrecordsonthedaythe question-nairewasadministered.SLEDAIisaspecificinstrument;thus,

itshouldonlybeusedingroupswithpatientswhomeetthe classificationcriteriaforSLEandnotintheFM-onlygroup.

ThroughtheSymptomSeverityIndex(SSI),26_{theseverityof}

themainsymptomsinpatientswithFM,exceptforthepain, wasverified.Thisquestionnairehasarangefrom0to12,0 beingthelowestand12thehighestintensityofsymptoms.

GeneralizedPain Index (GPI)26 _{wasused toevaluatethe}

extentofpain.GPI showsthenumber ofareas ofthe body havingpain.Thisindexvariesbetween0and19.

BothGPIandSSIareindexesthatcomprisethePreliminary DiagnosticCriteriaforFibromyalgia,2010.26_{Bybeingspecific,}

GPIandSSIareinstrumentsthatshouldonlybeusedingroups ofpatientswhofulfillthecriteriaofclassificationforFMand notinSLE-onlygroups.

SF-3627_{isagenericquestionnaireforassessingthe}

qual-ityoflife,consistingofeightdomains:functioningcapacity, physicallimitations,generalhealth,vitality, mentalhealth, andsocialandemotionalaspects.Eachscalehasascore ran-gingfrom0to100,wherezeroistheworstpossiblequalityof lifeand100thebestQoLscenario.

For the analysis ofthe results, the followingtestswere used:Mann–WhitneytestwiththeaimofcomparingtheFM andFM/SLEgroupsinrelationtotheFIQandSSIvalues; analy-sisofvarianceofKruskal–Wallisforthepurposeofcomparing SLE,FMandFM/SLEgroupswithrespecttothevaluesofVAS, GPIandtheeightdomainsofSF-36;andthechi-squaredtest withtheaimofcomparingSLE,FMandFM/SLEgroupswith respecttopercentagesofpresenceofhypertension,diabetes mellitusandosteoarticulardiseases.

Results

Sixty patients with FM, SLE and FM associated with SLE werestudiedfromSeptember2011untilAugust2012,being distributed equally intothree groups,namely, FM, LESand FM/LES.TheprevalenceofpatientswithFMamongpatients withSLEfollowedatCHSwas12%.Theaverageageofthe inter-viewedpatientswas44yearsforFMgroup,40forSLEgroup and43.5forFM/LESgroup.

Similarly,thepresenceofco-morbidities–diabetes melli-tus(DM)andsystemicarterialhypertension(SAH)–showed nosignificantdifference.Thevariables“diagnosisof depres-sion priorto the study”and “otherosteoarticular diseases (OAD)”weremorepresentinFM-presentinggroups(Table1). Regarding OAD, patients with FM referredmyofascial pain (5 patients),lowbackpain(4patients)andtendinopathy (6 patients).PatientswithSLEreportedtendinopathy(7patients) andlowbackpain(4patients).Ontheotherhand,patientsof FM/SLEgroupmentionedarthritis(1patient),tendinopathy(7 patients)andlowbackpain(10patients).

Table1–Clinicaldataofpatientsevaluated.

Variables/groups FM SLE SLE/FM P

Ageofdiseaseonset(median) 36 28 31.5/35.5 0.0638

PresenceofDM(n,%) 2(10%) 0 1(5%) 0.3499

SAH(n,%) 6(30%) 12(60%) 8(40%) 0.1496

PresenceofOAD(n,%) 15(75%) 11(55%) 18(90%) 0.0426a

Presenceofpreviousdepression(n,%) 16(80%) 3(15%) 12(60%) 0.0001a

n,number;DM,diabetesmellitus;SAH,systemicarterialhypertension;OAD,osteoarticulardiseases;p<or>0.05. a _{FMandSLE/FM>SLE.}

Consideringthatthepatientswerestudiedinthetertiary sectorofhealthcare,inthecaseofpatientswith fibromyal-giaweexpectanimportantparticipationofemotionalissues suchasdepression.Inthepresentstudyitwasnotpossibleto concludewhatistheinfluenceofdepressiononthequalityof lifeofthetwogroups,sincethisvariablehasnotbeenstudied withspecificinstruments.

ThroughGPI andSSI, weobservedagreater intensityof symptoms of fibromyalgia in patients who only had this syndrome, in comparisonwith those FM patients with an associationwithSLE.Thisfindingmayexplainthetendency foralowerimpact,citedabove,observedwiththeuseofFIQ. ThepresenceofFMinSLEpatientsdidnotinfluencethe clin-icalactivityofthisdisease,whenassessedbySLEDAI.

RegardingthequalityoflifemeasuredbySF-36,itcanbe seenthatthegroupswithFMhadamorenegativephysical, social,emotionalandmentalimpact,whencomparedtothe SLE-onlygroupinallitsscales.Thedomainsmostaffected byfibromyalgia were physicalaspects, pain and emotional aspects.InSLEpatients, thisanalysisdidnotdetect differ-ences between domains. On the other hand,in the group FM/LESthemostalteredscaleswerealsophysicaland emo-tionalaspects–thus,afindingsimilartotheFMgroup,again suggestingastronginfluenceofFMinSLE,andnototherwise.

Discussion

SLEisanautoimmunediseasethatcanaffectvariousorgans, especially the skin, musculoskeletal system and kidney,

among others.10 _{The literature has pointed to a higher}

prevalenceofFMinpatients withSLE,than inthegeneral population. TheprevalenceidentifiedofFMinSLEpatients inthisstudywas12%,slightlylowerthanthatfoundinthe literature,16–22_{rangingfrom17to22%.}

Intheevaluationofthecharacteristicsofpainand symp-tomintensitythroughVAS,GPI andSSIquestionnaires,the worst performances occurred in the groups presentingFM aloneorinassociationwithSLE.Thus,thepresenceofFMhas asignificantnegativeimpactonthequalityoflifeofpatients withSLE.Itshouldbeemphasized,however,thatmostofthe patientspertainingtothegroupofSLEinthisstudypresented nodiseaseactivity(SLEDAI=zero).

Thesefindingsareinagreementwiththeliterature,since studies haveshownthatFM,besidesbeingcommoninSLE patients, is the primary determinantofthe frequency and severityofsymptoms.Inaddition,FMcausesincapacityfor dailyactivities.17 _{Therefore, itislikelythat abettercontrol}

ofFMwould resultinimprovementinthequality oflifeof patientswithSLE.

InmostSF-36domains,weobservedaworseoutcomein theFM-onlygroup.TheFM/SLEgroupshowedintermediate values,whichmayindicatethatFMcontributestothe worsen-ingofhealthstatus.Thesepatientsaremoresymptomaticand dysfunctionalthanpatientsexclusivelywithLES. Fibromyal-giacausesasignificantnegativeimpactonthequalityoflifeof patients,showingastrongcorrelationwithintensityofpain, fatigueanddecreasedfunctionalcapacity.18,28,29

AccordingtoaCanadianstudy,thepresenceofFMinSLE patientswasnotrelatedtoanincreaseoftheparametersthat

Table2–Datafromclinicalactivityandimpactonqualityoflife.

Variables/groups FM SLE SLE/FM P

FIQ 71.3 – 59.89 0.0881

SLEDAI – 0.1 0.3 0.9892

GPI 15.05 – 11.75 0.0001

SSI 10.4 – 8.2 0.0152

SF-36functionalcapacity limitationsdueto physicalaspects

30.75 70.25 48.25 0.0008

Pain 87.5 35 71.25 0.0004

Generalhealth 17.9 73.68 37.6 <0.0001

Vitality 45.5 63.25 37.85 0.0067

Socialaspects 21.25 59.75 33 0.0009

Limitationduetoemotional aspects

44.43 76.25 55.63 0.0023

Mentalhealth 88.23 33.3 73.3 0.0014

makeupSLEDAI;however,thepresenceofFMhasastrong correlationwiththeeightdomainsofSF-36.29_Thus,FMisnot

relatedtodiseaseactivityinSLE,butcangeneratea misin-terpretationofitsactivity,duetotheclinicalfeaturesofFM, besidescontributingtoworseningthequalityoflifeinpatients withSLE.29

Despite the contribution ofFMto the worsening ofthe healthstatusofpatientswithSLE,ithasbeenshowninthe literaturethatFMcauseslittleornoimpactontheactivityof SLE,19,29_{whichcorroboratesthefindingsofourstudy,where}

nochangeinSLEDAIofrespectivegroups(SLE,FMandSLE/FM) wasnoted.

Inourstudy,patientswithSLEpresentedwithastable clin-icalpicture;thus,ourresultsmaynotreflecttherealityinthe acutephasesofSLE.

ThesampleofpatientswithbothFMand SLEdiffersin relationtowhatisobservedinthecommunity.Patientswith FMarethoseindividualsrefractorytoastandardtreatment, sincetheyareseenatatertiarylevelcenter,whileSLEpatients aregenerallytreatedattertiarycenters.Therefore,our sam-plemaynotreflectthegeneralpopulationofpatients with fibromyalgia.Acomplementtothisstudyintendstopropose theassessmentofpatients seenatprimary andsecondary sectors.

Conclusion

ThefrequencyofFMobservedinpatientswithSLEtreated atCHSis12%.Thepatientshadamean ageof40–44years inthethreegroups.ThepresenceofSLEhasnotdetermined agreaterimpactonquality oflifeofpatientswithSLE/FM, whenassessedbyFIQ.FM,inturn,alsodidnotresultinhigher levelsofLSEactivitymeasuredbySLEDAI.Ahigherintensityof symptomsintheFM-onlygroup,inrelationtotheassociation SLE/FM,wasnoted.ThepresenceofFMadverselyaffectsthe qualityoflifeofpatientswithSLE.

Funding

GrantPIBIC-CNPqforMedicinestudents.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1. CarvilleSF,Arendt-NielsenS,BliddalH,BlotmanF,BrancoJC, BuskilaD,etal.EULAR–evidence-basedrecommendations forthemanagementoffibromyalgiasyndrome.AnnRheum Dis.2008;67:536–41.

2. HeymannRE,PaivaES,HelfensteinMJ,PollakDF,MartinezJE, ProvenzaJR,etal.ConsensoBrasileirodoTratamentode Fibromialgia.RevBrasReumatol.2010;50:56–66.

3. AbelesAM,PillingerMH,SolitarBM,AbelesM.Narrative review:thepathophysiologyoffibromyalgia.AnnInternMed. 2007;146:726–34.

4.SennaER,DeBarrosAL,SilvaEO,CostaIF,PereiraLV,Ciconelli RM,etal.PrevalenceofrheumaticdiseasesinBrazil:astudy usingtheCOPCORDapproach.JRheumatol.2004;31:594–7.

5.CostaSRR,PereiraNetoMS,TavaresNetoJ,KubiakI,Dourado MS,AraújoAC,etal.Característicasdepacientescom síndromedafibromialgiaatendidosemumhospitalde SalvadorBA-Brasil.RevBrasReumatol.2005;45:64–70.

6.BurckhardtCS,ClarkSR,BennettRM.Thefibromyalgia impactquestionnaire:developmentandvalidation.J Rheumatol.1991;18:728–33.

7.MartinezJE,FerrazMB,SatoEI,AtraE.Fibromyalgiavs rheumatoidarthritis:alongitudinalcomparisonofqualityof life.JRheumatol.1995;22:201–4.

8.SiegelM,LeeSL.Theepidemiologyofsystemiclupus erythematosus.SeminArthritisRheum.1973;3:1–54.

9.HopkinsonND,DohertyM,PowellRJ.Theprevalenceand incidenceofsystemiclupuserythematosusinNottingham UK,1989–1990.BrJRheumatol.1993;32:110–5.

10.FesselWJ.Systemiclupuserythematosusinthecommunity: incidence,prevalence,outcome,andfirstsymptoms;thehigh prevalenceinblackwomen.ArchInternMed.

1974;134:1027–35.

11.McCartyDJ,ManziS,MedsgerTAJr,Ramsey-GoldmanR, LaPorteRE,KwohCK.Incidenceofsystemiclupus erythematosus.Raceandgenderdifferences.Arthritis Rheum.1995;38:1260–70.

12.HochbergMC.Theincidenceofsystemicerythematosus lupusinBaltimore,Maryland,1970–1977.ArthritisRheum. 1985;28:80–6.

13.JohnsonAE,CavalcantiFS,GordonC,NivedO,PalmerRG, SturfeltG,etal.Crosssectionalanalysisofpatientswith systemiclupuserythematosusinEngland,Brazil,and Sweden.Lupus.1994;3:501–6.

14.BombardierC,GladmanDD,UrowitzMB,CaronD,ChangCH. TheCommitteeonPrognosisStudiesinSLE.Derivationofthe Sledai.Adiseaseactivityindexforlupuspatients.Arthritis Rheum.1992;35:630–40.

15.McElhoneK,AbbottJ,TehL-S.Areviewofhealthrelated qualityoflifeinsystemiclupuserythematosus.Lupus. 2006;15:633–43.

16.WolfeF,PetriM,AlarcónGS,GoldmanJ,ChakravartyEF,Katz RS,etal.Fibromyalgia.Systemiclupuserythematosus(SLE) andevaluationofSLEactivity.JRheumatol.2009;36:82–8.

17.MiddletonGD,McFarlinJE,LipskyPE.Theprevalenceand clinicalimpactoffibromyalgiainsystemiclupus erythematosus.ArthritisRheum.1994;37:1181–8.

18.GladmanDD,UrowitzMB,GoughJ,MacKinnonA.

Fibromyalgiaisamajorcontributortoqualityoflifeinlupus. JRheumatol.1997;24:2145–8.

19.AkkasilpaS,GoldmanD,MagderLS,PetriM.Numberof fibromyalgiatenderpointsisassociatedwithhealthstatusin patientswithsystemiclupuserythematosus.JRheumatol. 2005;32:48–50.

20.HandaR,AggarwalP,WaliJP,WigN,DwivediSN.

FibromyalgiainIndianpatientswithSLE.Lupus.1998;7:475–8.

21.Valencia-FloresM,CardielMH,SantiagoV,ResendizM, Casta ˜noVA,NegreteO,etal.Prevalenceandfactors associatedwithfibromyalgiainMexicanpatientswith systemiclupuserythematosus.Lupus.2004;13:4–10.

22.FriedmanAW,TewiMB,AhnC,McGwinGJr,FesslerBJ, BastianHM,etal.Systemiclupuserythematosusinthree ethnicgroups:XVprevalenceandcorrelatesoffibromyalgia. Lupus.2003;12:274–9.

24.WolfeF,SmytheHA,YunusMB,BennetRM,BombardierC, GoldenbergDL,etal.TheAmericanCollegeofRheumatology 1990criteriafortheclassificationoffibromyalgia.Reportof theMulticenterCriteriaCommittee.ArthritisRheum. 1990;33:160–72.

25.MarquesAP,SantosAMB,Assumpc¸ãoA,MatsutaniLA,Lage LV,PereiraCAB.Validac¸ãodaversãobrasileiradoFibromyalgia ImpactQuestionnaire(FIQ).RevBrasReumatol.2006;46: 24–31.

26.WolfeF,ClauwDJ,FitzcharlesMA,GoldenbergDL,KatzRS, MeaseP,etal.TheAmericanCollegeofRheumatology PreliminaryDiagnosticCriteriaforfibromyalgiaand

measurementofsymptomseverity.ArthritisCareRes. 2010;62:600–10.

27.CiconelliRM,FerrazMB,SantosW,MeinãoI,QuaresmaMR. Traduc¸ãoparalínguaportuguesaevalidac¸ãodoquestionário genéricodeavaliac¸ãodequalidadedevidaSF-36(Brasil SF-36).RevBrasReumatol.1999;39:143–50.

28.SegarraTV,AbellóCJ,OreiroCS,DomínguezMJM.Association betweenfibromyalgiaandpsychiatricdisordersinsystemic lupuserythematosus.ClinExpRheumatol.2001;28:S22–6.