Fibromyalgia and Hepatitis Viruses: What's the Connection?

Fibromyalgia may be linked to several viruses, including hepatitis B (HBV) and hepatitis C (HCV), which can lead to cirrhosis of the liver. Cirrhosis is a potentially serious late-stage disease that can cause significant pain and potentially fatal complications.

Studies over more than two decades have investigated the possible connections between the chronic pain condition fibromyalgia and hepatitis viruses, and this remains an active area of research.

What’s the Connection?

It might seem odd to look for a connection between infectious agents and a chronic pain condition. However, fibromyalgia is more than “just” pain.

It’s long been believed that fibromyalgia involves some dysregulation of the immune system. The exact nature of the immune dysfunction isn’t yet clear, but it may be that fibromyalgia involves an overactive immune system.

Some infectious agents may cause problems by lingering in the body and causing what’s called a smoldering infection, one that’s basically simmering forever without coming to a full boil, which keeps the immune system in constant battle.

Other pathogens may “hit and run,” causing a short-term illness that resolves but leaves the immune system damaged and unable to turn off.

Another theory holds that at least some cases of fibromyalgia may have an autoimmune component, in which the immune system attacks healthy tissues in your body as if they were dangerous pathogens.

Fibromyalgia has known associations with numerous autoimmune diseases, including:

• Rheumatoid arthritis
• Lupus
• Sjögren’s syndrome

Any of those factors may play a role in how common fibromyalgia is in liver disease. However, the link between fibromyalgia and the hepatitis viruses may have more to do with the psychological impact of having liver disease or the pain it causes.

Hepatitis B and C Viruses

Research on the link between fibromyalgia, hepatitis viruses, and cirrhosis of the liver goes back to 1997 and continues to this day. The link is well established between fibromyalgia and HCV and less so between HBV, although several studies now show an association.

Experts have offered a couple of possible explanations for this link, but thus far, none of them is proven. Cirrhosis is a condition involving inflammation, cellular degeneration, and thickening of tissues in the liver. The hepatitis viruses are common causes of cirrhosis. (Hepatitis literally means “liver inflammation.”)

The liver is a vital organ that performs several essential jobs in your body, including:

• Filtering your blood and removing toxins
• Processing nutrients from food
• Fighting off infections

Damage or inflammation of the liver can interfere with its function. Anyone with liver disease (or risk factors for it) needs to be especially careful with medications. That poses special problems for people trying to manage multiple conditions.

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The Research

A 2019 study looking at rheumatic diseases in people with HBV and HCV infections determined that fibromyalgia was the most prevalent condition.

Among the 70 patients with hepatitis, 54.3% were carriers of HBV and 45.7% of HCV. For patients infected with HBV and HCV, arthralgia was the most prevalent rheumatic manifestation in 97.4% and 90.6%, followed by myalgia in 81.6% and 65.6%, and arthritis in 26.3% and 40.6% of patients, respectively.

This number is somewhat higher than the reported prevalence in earlier studies. One noted that 22% of participants had both conditions, while the other found a 32% overlap. Researchers noted that all participants had rheumatic complaints, even those with extremely low viral loads.

For those with high viral loads, antiviral treatment often reduced rheumatological symptoms such as pain and inflammation, while those with low viral loads benefitted from treatments aimed at the specific rheumatic diagnosis.

Researchers speculated that fibromyalgia may be so common due to psychological factors. Stress and anxiety are both believed to contribute to the development of fibromyalgia. Therefore, researchers suggested, the anxiety and stress of having liver disease could trigger fibromyalgia.

This hypothesis appears to be supported by 2015 research that showed an association between fibromyalgia, HCV, and mood symptoms.

It should be pointed out, though, that many chronic illnesses are associated with psychological factors—including anxiety, stress, and depression—and fibromyalgia is not common in all of them. That suggests, at least in part, common underlying physiology.

The 2015 study also demonstrated that fibromyalgia symptoms were significantly linked to HCV and also with nonalcoholic steatohepatitis, but less so with alcohol-related liver disease.

While discussing mood symptoms as a commonality, these researchers also suggested a possible physiological reason for the association—central sensitization.

Considered by many to be a key feature of fibromyalgia, central sensitization means that the central nervous system is “sensitized” to pain signals and over-responds to them, which amplifies the pain signals received by the brain. This is called hyperalgesia.

Chronic pain, in some people, can lead to central sensitization. These researchers put forth the possibility that the abdominal pain experienced by people with liver disease could cause central sensitization, which leads to fibromyalgia symptoms.

Treatment Issues

Pain management for people with fibromyalgia and liver disease poses special problems.

Pain Treatment

Most pain medications are processed by the liver, and long-term use of them can seriously damage this organ. Both opioid painkillers such as Vicodin (hydrocodone/acetaminophen) and OxyContin (oxycodone) and nonsteroidal anti-inflammatory drugs (NSAIDs) like Motrin/Advil (ibuprofen) and Aleve (naproxen) can be hard on the liver.

The three drugs approved to treat fibromyalgia are not traditional pain medications. They target the abnormal neurology of fibromyalgia.

Even so, Cymbalta (duloxetine) and Savella (milnacipran) are both processed by the liver, and neither should be prescribed for someone with existing liver disease or who drinks a substantial amount of alcohol. In contrast, Lyrica (pregabalin) is processed mainly by the kidneys.

According to a 2018 report, little research has been done about how to manage pain in people with liver disease, and almost nothing is known about non-drug therapies.

The authors recommended research on a multi-dimensional approach involving other kinds of treatments, including:

• Physical therapy
• Weight loss
• Transcutaneous electrical nerve stimulation
• Acupuncture or acupressure
• Local anesthetic injections
• Cognitive-behavioral therapy
• Hypnosis
• Mindfulness meditation
• Topical analgesics, such as lidocaine patches or capsaicin cream

They also suggest treating co-morbid conditions, including:

• Anxiety
• Depression
• Substance abuse

Most fibromyalgia experts also recommend a multi-dimensional approach that can involve many of those treatments. That’s good news for people trying to manage both, as most of the treatments can do double-duty.

The report’s authors also suggested research into two medications—acetaminophen and gabapentin.

Acetaminophen is the drug in Tylenol and many other prescription and over-the-counter products. It carries a risk of liver toxicity if you take too much, but at low doses, it’s easier on the liver than NSAIDs and opioids. Research suggests that a dose of 2 grams per day is generally safe in people with cirrhosis.

Acetaminophen isn’t known to have much of a direct impact on fibromyalgia pain. However, chronic pain from other sources can exacerbate fibromyalgia symptoms, so anything that can lower the level of liver pain may help quiet fibromyalgia symptoms, as well.

Gabapentin is the drug in Neurontin, which is chemically similar to Lyrica. It’s frequently prescribed off-label for fibromyalgia, so it may be a viable alternative for someone with both fibromyalgia and liver disease. The report mentions that Lyrica has been associated with rare reports of liver injury, so it’s not viewed as favorably.

Cannabis-based treatments are becoming more common for treating all kinds of pain. Some of these treatments include synthetic cannabinoids made by drug companies, including Marinol dronabinol and Cesamet (nabilone). Others may use cannabidiol (CBD) products or, where allowed, medical marijuana.

However, researchers point out that not only is more work needed to determine whether any form of cannabis is safe and effective for cirrhosis, it also may pose a problem for anyone with liver damage related to substance abuse.

Depression Treatment

Treating depression, which often results from chronic illness, can be especially difficult for someone with fibromyalgia and liver cirrhosis. Antidepressants, which often are used to treat the pain of fibromyalgia, can pose problems for the liver. Nearly every class of these drugs has been shown to cause liver damage.

Tricyclic antidepressants accumulate in the body, and this accumulation is associated with progressive liver disease. Tricyclics include:

• Nortriptyline
• Desipramine
• Amitriptyline
• Imipramine
• Doxepin

Of these, nortriptyline and desipramine are the preferred choices for someone with liver disease, but they’re still not recommended.

Selective serotonin reuptake inhibitors (SSRIs) tend to be more often used in liver disease, but researchers say more investigation is needed to determine how safe they are for people with cirrhosis.

Serotonin-norepinephrine reuptake inhibitors (SNRIs), the class that includes both Cymbalta and Savella, are not believed to be good options for this population.

Other Infectious Agents

For more than 30 years, numerous infectious agents have been investigated for possible links to fibromyalgia. Some lines of inquiry have died out, but others remain viable. Some of the strongest evidence suggests a connection between fibromyalgia and:

• Epstein-Barr virus (EBV)
• Human herpesvirus 6 (HHV-6)
• Human herpesvirus 7 (HHV-7)
• Cytomegalovirus (CMV)
• Human immunodeficiency virus (HIV)
• Parvovirus B19
• Lyme disease
• Mycoplasma

It’s unknown why these pathogens may be associated with fibromyalgia. So far, experts haven’t found solid evidence of hit-and-run effects or smoldering infections. It’s also too soon to say whether fibromyalgia may be triggered by specific symptoms of diseases caused by these agents or common underlying mechanisms.

A Word From Verywell

If you have liver disease from hepatitis B or hepatitis C, it’s important for you to know about the risks of developing fibromyalgia. It’s a good idea to familiarize yourself with the symptoms and report them to your healthcare provider if you’re experiencing them.

Because untreated pain may put you at a higher risk of fibromyalgia, discuss pain-management options with your practitioner, and consider non-drug treatments whenever possible.