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For Some Patients with Rheumatoid Arthritis, Oral Analgesics May Not Improve Quality of Life

October 22, 2020
Individuals in clinical remission but still experiencing pain may need additional treatment methods to fully function.

A PPM Brief

Over the past 20 years or so, a better understanding of the pathologies behind rheumatoid arthritis (RA) has led to new therapies that have largely revolutionized treatment and outcomes.1 However, getting control of the underlying inflammatory process with RA does not necessarily mean controlling all the symptoms of the disease.

“Depending on how you define things, and what study you are looking at, anywhere from 30 to 50% to even 60% of patients who achieve clinical remission by the usual standards will continue to have symptoms of pain and limited function,” said Kevin Byram, MD, assistant professor of medicine, in the Division of Rheumatology and Immunology and Associate Director, Rheumatology Training Program, at the Vanderbilt University Medical Center.

The reasons for this vary, but Dr. Byram says one common cause of pain is damage left behind from RA. “Our anti-inflammatory and advanced medicines are really good at calming down active inflammation, but that active inflammation causes damage to joints, even on a microscopic level.” This can be challenging for physicians trying to improve the quality of life for patients who are otherwise responding well to standard treatment but still suffering pain and reduced function.

Researchers from the medical faculty at Saga University in Saga Prefecture, Japan, recently investigated the quality of life (QoL) in patients with rheumatoid arthritis, looking particularly at pain and QoL in those who were in clinical remission but still suffered from pain and limited function. The results of their analysis indicated that the use of oral analgesics and ratings of pain self-efficacy are independent predictions of QoL in these patients.

Methods

The single-center, cross-sectional study, conducted in 2016, included 85 patients. All subjects had a confirmed diagnosis of RA according to the criteria set by the American College of Rheumatology and the European League Against Rheumatism. Study variables included use of oral pain medications, disease-modifying anti-rheumatic drugs (DMARDs, both synthetic and biologic), and NSAIDs.

Tests to evaluate pain levels, disease activity, and QoL included the EQ-5D-5L (European Quality of Life questionnaire with five dimensions and five levels, a common health-related quality of life measurement tool); the DAS28-CRP (28-joint disease activity score with C-reactive protein, to measure disease activity); the PDQ (painDETECT questionnaire, to measure non-inflammatory, neuropathic or sensitization elements of pain); the PSEQ (pain self-efficacy questionnaire, to measure the patient’s self-efficacy, or confidence in performing activities in spite of pain); and the PCS (pain catastrophizing scale, an assessment of the degree of pain catastrophizing).

 

Findings

Several factors affected patients’ QoL, according to this study results. These included the length of time the patient had the disease; PDQ, PSEQ, and PCS scores’ and the use of oral steroids and oral analgesics. The use of oral analgesics and PSEQ scores had particularly strong associations with QoL in this set of patients. Those who took oral analgesics were far more likely to report a low score on the PSEQ question that asked, “I can cope with my pain without medications” than patients who did not take oral analgesics. This led the researchers to suggest that “pain control with only oral analgesics may lead to reduced QOL.”2

The authors concluded that because many patients with RA achieve DAS28-CRP remission yet continue to have clinically significant pain, “only utilizing the DAS28-CRP for the assessment and treatment of RA disease activity … may fail to improve quality of life.”2 Therefore, they recommend various pain management strategies be considered for the treatment of RA. Strategies include surgical treatment as well as psychological approaches (eg, Acceptance and Commitment Therapy, and Cognitive Behavioral Therapy), to help reduce pain intensity and increase patient self-efficacy. In addition, the authors suggest that the PSEQ scale be used when assessing the efficacy of treatments.

Of noe, older age and longer disease duration were also shown to be risk factors for poor QoL, leading the researchers to suggest that elderly patients with rheumatoid arthritis and those with long disease duration may require a different treatment model than other patients.

 

Challenges in Treatment

The challenges of treating RA pain in patients in remission are indeed complex. Dr. Byram, who was not a part of the Japanese review, pointed out that some pain may occur due to concomitant conditions, such as osteoarthritis or fibromyalgia. In addition, he said it is possible that patients who take oral analgesics, “have a high damage burden, leaving them prone to having symptoms.”

However, Dr. Byram does agree that CBT can be a useful approach. “I would love to use it more than I do, but access can be a challenge. You need a trained therapist to do that and those types of resources are limited in most places. Still, it can be really effective,” he noted.

 

Last updated on: October 22, 2020
Continue Reading:
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
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