Pain persists in DAS28 rheumatoid arthritis remission but not in ACR/EULAR remission: a longitudinal observational study

Objective. To identify predictors of pain at 1 year in patients with early inflammatory polyarthritis (EIP).Methods. Using a prospective design, patients were examined by a rheumatologist and completed questionnaires at baseline and at 1 year after symptom onset. Separate regression analyses were run for pain intensity, sensory pain, and affective pain. Age and sex were adjusted in cross-sectional and longitudinal analyses; baseline potential predictors consisted of measures for corresponding pain values and disease activity, depression, coping scores, medication use, rheumatoid arthritis criteria being met, and duration of symptoms. Results. A total of 211 patients were enrolled in the study (mean ؎ SD age 58.8 ؎ 14.2 years, 63% women). There were significant improvements at 1 year for disease activity, instrumental coping, emotional coping, depression, and all 3 pain measures. At baseline, disease activity and depression were positively associated with all types of pain; in addition, instrumental coping was positively associated with sensory pain and palliative coping was positively associated with affective pain. At 1 year, pain intensity was predicted by baseline pain intensity, duration of symptoms, use of disease-modifying antirheumatic drugs (DMARDs), and emotional coping. Sensory pain was predicted by baseline sensory pain and DMARD use. Affective pain was predicted by baseline affective pain, DMARD use, and emotional coping. Conclusion. The majority of treated EIP patients can expect improvements in clinical and psychosocial variables over the first year of their illness. Emotional coping at baseline may contribute to pain in the future, and therefore it may be useful for patients to learn other means of dealing with this chronic disease.

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Predictors of Pain for Patients With Early Inflammatory Polyarthritis

Dobkin

Liu

Abrahamowicz

et al. 2013

“…In early arthritis, active joint inflammation causes a significant burden of pain. However, several earlier observations indicate an uncoupling of pain and joint inflammation during the disease course and show that pain may persist in inflammatory remission 4, 5. These findings indicate that pain, not directly related to inflammation, may be insufficiently controlled by antirheumatic drugs, and there is a lack of earlier studies of the pain pattern related to treatment response in early RA.…”

Section: Introductionmentioning

confidence: 92%

Remaining Pain in Early Rheumatoid Arthritis Patients Treated With Methotrexate

Altawil

Saevarsdóttir

Wedrén

et al. 2016

ObjectiveTo investigate the frequency of remaining pain in early rheumatoid arthritis (RA) after 3 months of treatment with methotrexate as the only disease modifying antirheumatic drug, with a special focus on patients with a good clinical response.MethodsThe study base was cases reported to a population‐based early RA cohort who had followup data from the Swedish Rheumatology Quality Register (n = 1,241). The Disease Activity Score in 28 joints European League Against Rheumatism (EULAR) response criteria were used to evaluate clinical response to treatment as good, moderate, and no response. The primary end point was remaining pain at the 3‐months followup visit, defined as pain >20 mm on a 100‐mm visual analog scale (VAS).ResultsRemaining pain in spite of a EULAR good response at followup was associated with higher baseline disability, using the Health Assessment Questionnaire (adjusted odds ratio [OR] 2.2 [95% confidence interval (95% CI) 1.4–3.4] per unit increase), and less baseline inflammation, using the erythrocyte sedimentation rate (adjusted OR 0.81 [95% CI 0.70–0.93] per 10‐mm increase). Similar associations were detected for remaining pain at followup in spite of low inflammatory activity, defined as a C‐reactive protein level <10. Increase in VAS pain during the treatment period was observed in 19% of the whole cohort, with frequencies in the EULAR response groups of 9% (good response), 15% (moderate response), and 45% (no response).ConclusionThese results are in line with the hypothesis that a subgroup of early RA patients exhibits pain that is not inflammatory mediated, where alternative treatment strategies to traditional antiinflammatory medications need to be considered.

“…In previous consensus guidelines, remission was operationally defined as a Disease Activity Score in 28 joints using C‐reactive protein level (DAS28‐CRP) of <2.6 12. However, some patients with DAS28‐CRP <2.6 experience residual disease activity, including inflammation, pain, and joint tenderness and swelling in ankle and foot joints 5, 13, 14, 15, 16, 17, 18. Although DAS28‐CRP <2.6 no longer constitutes remission, it remains a valid treatment target.…”

Section: Introductionmentioning

confidence: 99%

Effects of Achieving Target Measures in Rheumatoid Arthritis on Functional Status, Quality of Life, and Resource Utilization: Analysis of Clinical Practice Data

Alemao

Joo

Kawabata

et al. 2016

ObjectiveTo evaluate associations between achieving guideline‐recommended targets of disease activity, defined by the Disease Activity Score in 28 joints using C‐reactive protein level (DAS28‐CRP) <2.6, the Simplified Disease Activity Index (SDAI) ≤3.3, or the Clinical Disease Activity Index (CDAI) ≤2.8, and other health outcomes in a longitudinal observational study.MethodsOther defined thresholds included low disease activity (LDA), moderate (MDA), or severe disease activity (SDA). To control for intraclass correlation and estimate effects of independent variables on outcomes of the modified Health Assessment Questionnaire (M‐HAQ), the EuroQol 5‐domain (EQ‐5D; a quality‐of‐life measure), hospitalization, and durable medical equipment (DME) use, we employed mixed models for continuous outcomes and generalized estimating equations for binary outcomes.ResultsAmong 1,297 subjects, achievement (versus nonachievement) of recommended disease targets was associated with enhanced physical functioning and lower health resource utilization. After controlling for baseline covariates, achievement of disease targets (versus LDA) was associated with significantly enhanced physical functioning based on SDAI ≤3.3 (ΔM‐HAQ −0.047; P = 0.0100) and CDAI ≤2.8 (−0.073; P = 0.0003) but not DAS28‐CRP <2.6 (−0.022; P = 0.1735). Target attainment was associated with significantly improved EQ‐5D (0.022–0.096; P < 0.0030 versus LDA, MDA, or SDA). Patients achieving guideline‐recommended disease targets were 36–45% less likely to be hospitalized (P < 0.0500) and 23–45% less likely to utilize DME (P < 0.0100).ConclusionAttaining recommended target disease‐activity measures was associated with enhanced physical functioning and health‐related quality of life. Some health outcomes were similar in subjects attaining guideline targets versus LDA. Achieving LDA is a worthy clinical objective in some patients.