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Effect and Treatment of Chronic Pain in Inflammatory Arthritis

Current Rheumatology Reports volume 15, Article number: 300 (2013) Cite this article

Abstract

Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy. Although several studies have examined the effects of reducing inflammation for patients with inflammatory arthritis, very few clinical trials have examined the safety and efficacy of treatment directed specifically towards pain pathways. Most studies have been small, have focused on rheumatoid arthritis or mixed populations (e.g., rheumatoid arthritis plus osteoarthritis), and have been at high risk of bias. Larger, longitudinal studies are needed to examine the mechanisms of pain in inflammatory arthritis and to determine the safety and efficacy of analgesic medications in this specific patient population.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education and research. Washington, DC: The National Academies Press; 2011.

  2. Heiberg T, Finset A, Uhlig T, Kvien TK. Seven year changes in health status and priorities for improvement of health in patients with rheumatoid arthritis. Ann Rheum Dis. 2005;64(2):191–5.

    PubMed  Article  CAS  Google Scholar 

  3. ten Klooster PM, Veehof MM, Taal E, van Riel PL, van de Laar MA. Changes in priorities for improvement in patients with rheumatoid arthritis during 1 year of anti-tumour necrosis factor treatment. Ann Rheum Dis. 2007;66(11):1485–90. Epub 2007 May 1.

    PubMed  Article  Google Scholar 

  4. •• Borenstein D, Altman R, Bello A, Chatham W, Clauw DJ, Crofford LJ, et al. Report of the American college of rheumatology pain management task force. Arthritis Care Res. 2010;62(5):590–9. This article summarizes the importance of pain in the systemic rheumatic diseases and highlights the critical gaps in education, research, and treatment that must be addressed to better manage pain in patients with systemic rheumatic diseases.

    Article  Google Scholar 

  5. Strand V, Burmester GR, Ogale S, Devenport J, John A, Emery P. Improvements in health-related quality of life after treatment with tocilizumab in patients with rheumatoid arthritis refractory to tumour necrosis factor inhibitors: results from the 24-week randomized controlled RADIATE study. Rheumatology (Oxford). 2012;51(10):1860–9.

    Google Scholar 

  6. Wolfe F, Michaud K. Assessment of pain in rheumatoid arthritis: minimal clinically significant difference, predictors, and the effect of anti-tumor necrosis factor therapy. J Rheumatol. 2007;34(8):1674–83.

    PubMed  Google Scholar 

  7. Lee YC, Cui J, Lu B, Frits ML, Iannaccone CK, Shadick NA, et al. Pain persists in DAS28 rheumatoid arthritis remission but not in ACR/EULAR remission: a longitudinal observational study. Arthritis Res Ther. 2011;13(3):R83.

    PubMed  Article  Google Scholar 

  8. Kawaguchi Y, Matsuno H, Kanamori M, Ishihara H, Ohmori K, Kimura T. Radiologic findings of the lumbar spine in patients with rheumatoid arthritis, and a review of pathologic mechanisms. J Spinal Disord Tech. 2003;16(1):38–43.

    PubMed  Article  Google Scholar 

  9. Helliwell PS, Zebouni LN, Porter G, Wright V. A clinical and radiological study of back pain in rheumatoid arthritis. Br J Rheumatol. 1993;32(3):216–21.

    PubMed  Article  CAS  Google Scholar 

  10. Neva MH, Hakkinen A, Isomaki P, Sokka T. Chronic back pain in patients with rheumatoid arthritis and in a control population: prevalence and disability—a 5-year follow-up. Rheumatology (Oxford). 2011;50(9):1635–9.

    Article  Google Scholar 

  11. Ranzolin A, Brenol JC, Bredemeier M, Guarienti J, Rizzatti M, Feldman D, et al. Association of concomitant fibromyalgia with worse disease activity score in 28 joints, health assessment questionnaire, and short form 36 scores in patients with rheumatoid arthritis. Arthritis Rheum. 2009;61(6):794–800.

    PubMed  Article  Google Scholar 

  12. Wolfe F, Cathey MA, Kleinheksel SM. Fibrositis (Fibromyalgia) in rheumatoid arthritis. J Rheumatol. 1984;11(6):814–8.

    PubMed  CAS  Google Scholar 

  13. Wolfe F, Hauser W, Hassett AL, Katz RS, Walitt BT. The development of fibromyalgia—I: examination of rates and predictors in patients with Rheumatoid Arthritis (RA). Pain. 2011;152(2):291–9.

    PubMed  Article  Google Scholar 

  14. Lee YC, Lu B, Boire G, Haraoui BP, Hitchon CA, Pope JE, et al. Incidence and predictors of secondary fibromyalgia in an early arthritis cohort. Ann Rheum Dis. 2012. doi:10.1136/annrheumdis-2012-201506

  15. Lee YC, Lu B, Bathon JM, Haythornthwaite JA, Smith MT, Page GG, et al. Pain sensitivity and pain reactivity in osteoarthritis. Arthritis Care Res. 2011;63(3):320–7.

    Google Scholar 

  16. Murphy SL, Lyden AK, Phillips K, Clauw DJ, Williams DA. Subgroups of older adults with osteoarthritis based upon differing comorbid symptom presentations and potential underlying pain mechanisms. Arthritis Res Ther. 2011;13(4):R135.

    PubMed  Article  Google Scholar 

  17. Murphy SL, Lyden AK, Phillips K, Clauw DJ, Williams DA. Association between pain, radiographic severity, and centrally-mediated symptoms in women with knee osteoarthritis. Arthritis Care Res. 2011;63(11):1543–9.

    Article  Google Scholar 

  18. Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, et al. Sensitization in patients with painful knee osteoarthritis. Pain. 2010 Apr 23.

  19. Lee YC, Nassikas NJ, Clauw DJ. The role of the central nervous system in the generation and maintenance of chronic pain in rheumatoid arthritis, osteoarthritis and fibromyalgia. Arthritis Res Ther. 2011;13(2):211.

    PubMed  Article  Google Scholar 

  20. Huskisson EC, Hart FD. Pain threshold and arthritis. Br Med J. 1972;4(5834):193–5.

    PubMed  Article  CAS  Google Scholar 

  21. Gerecz-Simon EM, Tunks ER, Heale JA, Kean WF, Buchanan WW. Measurement of pain threshold in patients with rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and healthy controls. Clin Rheumatol. 1989;8(4):467–74.

    PubMed  Article  CAS  Google Scholar 

  22. Le Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (DNIC). I. Effects on dorsal horn convergent neurones in the rat. Pain. 1979;6(3):283–304.

    PubMed  Article  Google Scholar 

  23. Woolf CJ. Evidence for a central component of post-injury pain hypersensitivity. Nature. 1983;306(5944):686–8.

    PubMed  Article  CAS  Google Scholar 

  24. Wilder-Smith CH, Robert-Yap J. Abnormal endogenous pain modulation and somatic and visceral hypersensitivity in female patients with irritable bowel syndrome. World J Gastroenterol. 2007;13(27):3699–704.

    PubMed  Google Scholar 

  25. Kosek E, Ordeberg G. Lack of pressure pain modulation by heterotopic noxious conditioning stimulation in patients with painful osteoarthritis before, but not following, surgical pain relief. Pain. 2000;88(1):69–78.

    PubMed  Article  CAS  Google Scholar 

  26. Khan NA, Spencer HJ, Abda E, Aggarwal A, Alten R, Ancuta C, et al. Determinants of discordance in patients' and physicians' rating of rheumatoid arthritis disease activity. Arthritis Care Res. 2012;64(2):206–14.

    Article  Google Scholar 

  27. • Studenic P, Radner H, Smolen JS, Aletaha D. Discrepancies between patients and physicians in the perception of rheumatoid arthritis disease activity. Arthritis Rheum. 2012;64(9):2814–23. This article reports that pain is the most significant predictor of patient global assessment of disease activity and the most significant predictor of discrepant patient and physician global assessment scores, when patients rate disease activity higher than physicians.

    Google Scholar 

  28. Pollard LC, Kingsley GH, Choy EH, Scott DL. Fibromyalgic rheumatoid arthritis and disease assessment. Rheumatology (Oxford). 2010;49(5):924–8.

    Article  Google Scholar 

  29. Ton E, Bakker MF, Verstappen SM, Ter Borg EJ, van Albada-Kuipers IA, Schenk Y, et al. Look beyond the Disease Activity Score of 28 joints (DAS28): tender points influence the DAS28 in patients with rheumatoid arthritis. J Rheumatol. 2012;39(1):22–7.

    PubMed  Article  Google Scholar 

  30. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American college of rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum. 1990;33(2):160–72.

    PubMed  Article  CAS  Google Scholar 

  31. Pollard LC, Ibrahim F, Choy EH, Scott DL. Pain thresholds in rheumatoid arthritis: the effect of tender point counts and disease duration. J Rheumatol. 2012;39(1):28–31.

    PubMed  Article  Google Scholar 

  32. Haverman L, Grootenhuis MA, van den Berg JM, van Veenendaal M, Dolman KM, Swart JF, et al. Predictors of health-related quality of life in children and adolescents with juvenile idiopathic arthritis: results from a web-based survey. Arthritis Care Res. 2012;64(5):694–703.

    Article  CAS  Google Scholar 

  33. Courvoisier DS, Agoritsas T, Glauser J, Michaud K, Wolfe F, Cantoni E, et al. Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis. Arthritis Care Res. 2012;64(2):190–6.

    Article  Google Scholar 

  34. Husted JA, Tom BD, Farewell VT, Gladman DD. Longitudinal study of the bidirectional association between pain and depressive symptoms in patients with psoriatic arthritis. Arthritis Care Res. 2012;64(5):758–65.

    Article  Google Scholar 

  35. Lee YC, Chibnik LB, Lu B, Wasan AD, Edwards RR, Fossel AH, et al. The relationship between disease activity, sleep, psychiatric distress and pain sensitivity in rheumatoid arthritis: a cross-sectional study. Arthritis Res Ther. 2009;11(5):R160.

    PubMed  Article  Google Scholar 

  36. Butbul Aviel Y, Stremler R, Benseler SM, Cameron B, Laxer RM, Ota S, et al. Sleep and fatigue and the relationship to pain, disease activity and quality of life in juvenile idiopathic arthritis and juvenile dermatomyositis. Rheumatology (Oxford). 2011;50(11):2051–60.

    Article  Google Scholar 

  37. Nicassio PM, Ormseth SR, Kay M, Custodio M, Irwin MR, Olmstead R, et al. The contribution of pain and depression to self-reported sleep disturbance in patients with rheumatoid arthritis. Pain. 2012;153(1):107–12.

    PubMed  Article  Google Scholar 

  38. Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Fitzgerald JD, Ranganath VK, et al. Sleep loss exacerbates fatigue, depression, and pain in rheumatoid arthritis. Sleep. 2012;35(4):537–43.

    PubMed  Google Scholar 

  39. Knittle K, Maes S, de Gucht V. Psychological interventions for rheumatoid arthritis: examining the role of self-regulation with a systematic review and meta-analysis of randomized controlled trials. Arthritis Care Res. 2010;62(10):1460–72.

    Article  Google Scholar 

  40. Knittle KP, De Gucht V, Hurkmans EJ, Vlieland TP, Peeters AJ, Ronday HK, et al. Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis. Arthritis Care Res. 2011;63(11):1613–9.

    Article  Google Scholar 

  41. •• Whittle SL, Colebatch AN, Buchbinder R, Edwards CJ, Adams K, Englbrecht M, et al. Multinational evidence-based recommendations for pain management by pharmacotherapy in inflammatory arthritis: integrating systematic literature research and expert opinion of a broad panel of rheumatologists in the 3e initiative. Rheumatology (Oxford). 2012;51(8):1416–25. This article provides evidence and expert-based recommendations for the treatment of pain in patients with inflammatory arthritis.

    Article  Google Scholar 

  42. van der Goes MC, Jacobs JW, Boers M, Andrews T, Blom-Bakkers MA, Buttgereit F, et al. Monitoring adverse events of low-dose glucocorticoid therapy: EULAR recommendations for clinical trials and daily practice. Ann Rheum Dis. 2010;69(11):1913–9.

    PubMed  Article  Google Scholar 

  43. Whittle SL, Richards BL, Husni E, Buchbinder R. Opioid therapy for treating rheumatoid arthritis pain. Cochrane Database Syst Rev. 2011;(11):CD003113.

  44. Crofford LJ. Adverse effects of chronic opioid therapy for chronic musculoskeletal pain. Nat Rev. 2010;6(4):191–7.

    CAS  Google Scholar 

  45. Richards BL, Whittle SL, Buchbinder R. Neuromodulators for pain management in rheumatoid arthritis. Cochrane Database Syst Rev. 2012;1:CD008921.

    PubMed  Google Scholar 

  46. Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck Jr PE, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56(4):1336–44.

    PubMed  Article  CAS  Google Scholar 

  47. Crofford LJ, Mease PJ, Simpson SL, Young Jr JP, Martin SA, Haig GM, et al. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008;136(3):419–31.

    PubMed  Article  CAS  Google Scholar 

  48. Mease PJ, Russell IJ, Arnold LM, Florian H, Young Jr JP, Martin SA, et al. A randomized, double-blind, placebo-controlled, phase III trial of pregabalin in the treatment of patients with fibromyalgia. J Rheumatol. 2008;35(3):502–14.

    PubMed  CAS  Google Scholar 

  49. Richards BL, Whittle SL, Buchbinder R. Antidepressants for pain management in rheumatoid arthritis. Cochrane Database Syst Rev. 2011;(11):CD008920.

  50. Richards BL, Whittle SL, Buchbinder R. Muscle relaxants for pain management in rheumatoid arthritis. Cochrane Database Syst Rev. 2012;1:CD008922.

    PubMed  Google Scholar 

  51. Ramiro S, Radner H, van der Heijde D, van Tubergen A, Buchbinder R, Aletaha D, et al. Combination therapy for pain management in inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis). Cochrane Database Syst Rev. 2011;(10):CD008886.

  52. Marks JL, Colebatch AN, Buchbinder R, Edwards CJ. Pain management for rheumatoid arthritis and cardiovascular or renal comorbidity. Cochrane Database Syst Rev. 2011;(10):CD008952.

  53. Radner H, Ramiro S, Buchbinder R, Landewe RB, van der Heijde D, Aletaha D. Pain management for inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other spondylarthritis) and gastrointestinal or liver comorbidity. Cochrane Database Syst Rev. 2012;1:CD008951.

    PubMed  Google Scholar 

  54. Roth SH, Boost G. An open trial of naproxen in rheumatoid arthritis patients with significant esophageal, gastric, and duodenal lesions. J Clin Pharmacol. 1975;15(4 Pt. 2):378–84.

    PubMed  CAS  Google Scholar 

  55. Laine L, Curtis SP, Langman M, Jensen DM, Cryer B, Kaur A, et al. Lower gastrointestinal events in a double-blind trial of the cyclo-oxygenase-2 selective inhibitor etoricoxib and the traditional nonsteroidal anti-inflammatory drug diclofenac. Gastroenterology. 2008;135(5):1517–25.

    PubMed  Article  CAS  Google Scholar 

  56. Chan FK, Lanas A, Scheiman J, Berger MF, Nguyen H, Goldstein JL. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR): a randomised trial. Lancet. 2010;376(9736):173–9.

    PubMed  Article  CAS  Google Scholar 

  57. Colebatch AN, Marks JL, Edwards CJ. Safety of non-steroidal anti-inflammatory drugs, including aspirin and paracetamol (acetaminophen) in people receiving methotrexate for inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis). Cochrane Database Syst Rev. 2011;(11):CD008872.

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Disclosure

Dr Lee has received grant support from Forest Laboratories and has owned stock/stock options in Merck and Co., Novartis, and Elan Corp.

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  1. Division of Rheumatology, Brigham and Women’s Hospital, 75 Francis Street, PBB-B3, Boston, MA, 02115, USA

    Yvonne C. Lee

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Correspondence to Yvonne C. Lee.

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This article is part of the Topical Collection on Chronic Pain

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Lee, Y.C. Effect and Treatment of Chronic Pain in Inflammatory Arthritis. Curr Rheumatol Rep 15, 300 (2013). https://doi.org/10.1007/s11926-012-0300-4

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Keywords

  • Arthritis
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Fibromyalgia
  • Pain
  • Chronic pain
  • Quality of life
  • Comorbidity
  • Treatment
  • Non-steroidal anti-inflammatory agents
  • NSAIDs
  • Opioid analgesics
  • Neurotransmitter agents
  • Antidepressive agents