Residual Pain in Inflammatory Rheumatic Diseases May Call for New Approach

Over the past 2 decades, the success of biologic disease-modifying antirheumatic drugs (bDMARDs) has transformed the focus of treatment of patients with rheumatoid arthritis (RA) or ankylosing spondylitis (AS), explained a mini review article published recently in Frontiers in Medicine.

“Due to this innovative treatment, the days are over when joint and spine deformities defined the condition of a person with RA or AS,” wrote Florian Berghea, MD, PhD, of the department of rheumatology at Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, and coauthors. “Nonetheless, expectations are higher today, and other clinical problems (not entirely solved by bDMARDs) seem to drive the drug selection during the span of rheumatic diseases. Most of these issues are covered by the term ‘unmet needs.’”

A common unmet need is residual pain in patients otherwise in biological remission. Pointing to new data on the mixed origins of residual pain and the need for treatment diversification, the article’s authors proposed fresh terminology for the clinical entity.

“All in all,” they wrote, “we believe this condition is far more complex than simple pain and includes other clinical aspects, too (like fatigue or mood changes), so the terms post-remission syndrome (PRS), and PRS pain might be more appropriate.”

Although pain is frequently reported, symptoms among patients with low disease activity are wide, the authors explained. Consequently, they believe a therapeutic arsenal beyond anti-inflammatory drugs may be necessary.

The article suggests rheumatologists consider approaches for PRS pain from other specialties, such as intensive care, neurology, and psychiatry.

“Tricyclic antidepressants, serotonin, and norepinephrine reuptake inhibitors, or selective serotonin reuptake inhibitors, are just a few classes of drugs efficient in pain therapy rarely used by rheumatologists,” the authors wrote. “A combination of bDMARDs, conventional synthetic DMARDs, or targeted synthetic DMARDs and some of these drugs might have a superior effect on PRS pain than a simple switch of various bDMARDs.”

Reference:
Berghea F, Berghea CE, Zaharia D, Trandafir AI, Nita EC, Vlad VM. Residual Pain in the Context of Selecting and Switching Biologic Therapy in Inflammatory Rheumatic Diseases. Front Med (Lausanne). 2021;8:712645. Published 2021 Aug 17. doi:10.3389/fmed.2021.712645