The prevalence of fibromyalgia in axial spondyloarthritis

Comorbid fibromyalgia, in axial spondyloarthritis (axSpA) has been shown to influence disease activity and function, and quality of life. Although several papers exist, there is no comprehensive and robust systematic review to determine the prevalence of fibromyalgia in this patient group. Thus, the aim of the current study was to provide a definitive estimate of prevalence of fibromyalgia in axSpA, and in axSpA sub-classifications. A systematic literature search was conducted in Ovid MEDLINE, EMBASE, Evidence Based Medicine (EBM), and Cochrane Library, updated to April 2020, combining keywords and relevant MeSH headings, to identify papers reporting the prevalence of fibromyalgia in axSpA, or data from which this could be computed. This was then combined in a meta-analysis with data from the Scotland Registry for Ankylosing Spondylitis (SIRAS), a national axSpA register in Scotland. Data was pooled using random or fixed effects models where heterogeneity was greater or lesser than 75%. From 3401 manuscripts initially identified, 15 papers were included in the final review, plus SIRAS, giving data from 16 separate sources. The prevalence of fibromyalgia, among a total of 5214 patients, was 16.4% (95% CI 12.3-20.5%). Prevalence varied with axSpA sub-classification: ankylosing spondylitis: 13.8% (9.1-18.6%); MRI positive non-radiographic axSpA 20.3% (6.5-34.1%); and 'clinical' disease: 11.1% (6.0-16.2%). Overall, around 1 in 6 patients with axSpA also meet criteria for fibromyalgia. While estimates from individual studies vary, comorbid fibromyalgia represents a considerable burden across all sub-classifications of axSpA. This emphasises that focusing management solely on inflammatory disease in this patient group is unlikely to yield optimal improvements in quality of life.