Background/Purpose: Pain remains the highest priority for improvement to patients with Rheumatoid Arthritis (RA). Analgesic prescription in RA was historically a stand-alone approach and afterwards in conjunction with different strategies incorporating early introduction of DMARDs.

We aim to explore the analgesics prescribed in patients with early RA with a favourable risk profile during the first 2 years in the Care in early RA (CareRA) trial.

Methods: Patients with early RA (≤1 year) and a low-risk profile recruited in the 2-year pragmatic investigator-initiated treat-to-target CareRA trial were studied. Low-risk patients (fulfilling 2/3: absence of erosions, negativity to rheumatoid factor and anti-citrullinated protein antibodies, low disease activity score) were randomized to either methotrexate (MTX) 15mg/week with a step-down glucocorticoid (GC) scheme (prednisone 30mg)-COBRA Slim-, or to MTX  15mg/week and no oral GC -Tight-Step-Up-(TSU). All concomitant prescriptions for analgesics for each patient were recorded, including name, dosage, frequency, start/end date and indication as free text. Chronic intake (≥90 days during the trial) of NSAIDs, acetaminophen, or opioids including tramadol, and antidepressants prescribed for musculoskeletal (MSK) pain were considered.

Comparisons were performed with chi-square when appropriate and corrected for multiple testing with Holm’s method.

Results: Of the 90 patients recruited in the low-risk group, 43 were randomized to COBRA Slim and 47 to TSU. COBRA Slim, had a total of 67 analgesic prescriptions for MSK pain during the trial for 26/43 (60%) patients of which 9/43(21%) daily chronically (DC). TSU had a total of 107 analgesic prescriptions for 43/47 (92%) patients of which 25/47(53%) DC. At baseline, 18/43 (42%) patients starting COBRA Slim and 28/47 (60%) starting TSU used analgesics (p=0.14). Before the start of the study 33/43 (77%) of patients in the COBRA Slim and 32/47 (68%) in the TSU arm had been using analgesics (p=0.5). The total number of patients on analgesics at any time during the study (p< 0.001) and chronically (p< 0.01) was significantly different between treatment arms. Number of patients DC on NSAIDs was also significantly different (p< 0.05) between COBRA Slim 6/43 (14%) and TSU 19/47 (40%). Figure 1 is a graphical representation of the drug intake at every visit week during the trial. Each mark is a prescribed analgesic per patient, per time point; a bigger mark means more than one prescription of the same analgesic type per patient per timepoint.

Conclusion: Almost every patient in TSU was prescribed an analgesic for MSK pain compared to 60% in the group treated with MTX and a step-down GC scheme (COBRA Slim). Chronic analgesic intake was more than double in TSU. It is notable that even in patients considered to have a favourable risk profile, when the initial treatment did not include oral GC bridging, there was a significant consumption of analgesics becoming chronic for a significant proportion of them. To benefit maximally from the window of opportunity for treating early RA, intensive remission induction strategies (with GCs) should be applied even in patients without traditional factors of poor prognosis.

Figure 1: Graphical representation of drug intake at every visit-week during the trial

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/patients-with-early-rheumatoid-arthritis-considered-to-have-a-favourable-risk-profile-and-treated-according-to-a-step-up-strategy-have-an-increased-risk-of-chronic-analgesic-consumption/