Persistent and Non-Articular Regional and Widespread Pain Are Common in Early Rheumatoid Arthritis, Impacting Remission Rates and Reflected in Patient Global Scores

Vivian P. Bykerk¹, Orit Schieir ², Marie-France Valois ³, Gilles Boire ⁴, Glen Hazlewood ⁵, Louis Bessette ⁶, Carol Hitchon ⁷, Diane Tin ⁸, Carter Thorne ⁹, Edward Keystone ¹⁰, Janet Pope ¹¹, Susan J. Bartlett ¹² and Canadian Early Arthritis Cohort (CATCH) Investigators ¹³, ¹Hospital for Special Surgery, New York, NY, ²University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada, ³McGill University, Montreal, Canada, ⁴Sherbrooke University, Sherbrooke, QC, Canada, ⁵University of Calgary, Calgary, AB, Canada, ⁶Laval University, Quebec City, QC, Canada, ⁷University of Manitoba, Winnipeg, Canada, ⁸Southlake Regional Health Centre, Newmarket, Canada, ⁹Southlake Regional Health Centre, Newmarket, ON, Canada, ¹⁰Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada, ¹¹Western University, London, ON, Canada, ¹²McGill University, Montreal, QC, Canada, ¹³Canadian Early Arthritis Cohort (CATCH) Study, Toronto, Canada

Meeting: 2019 ACR/ARP Annual Meeting

Keywords: Early Rheumatoid Arthritis, patient-reported outcome measures and remission, persistent pain, widespread pain

Session Information

Date: Sunday, November 10, 2019

Title: RA – Diagnosis, Manifestations, & Outcomes Poster I: Risk Factors, Predictors, & Prognosis

Session Type: Poster Session (Sunday)

Session Time: 9:00AM-11:00AM

Background/Purpose: Persisting pain (NRS ≥4,) (PP) and non-articular pain (NAP), reduces quality of life for patients with RA. NAP is often attributed to fibromyalgia (FM), though FM prevalence could be overestimated in patients with unrecognized regional pain (RP) syndromes. Our goal was to understand pain patterns (regional vs. widespread) and its impact on achieving remission in real-world early inflammatory arthritis (EIA) patients.

Methods: Data were from EIA patients (symptoms < 1 year) enrolled in a national prospective cohort study between Mar 2017 – Mar 2019 who completed body pain diagrams (BPD) at baseline (n=317) and repeat assessments every 3-months over 1 year follow up (n=122). Patients were grouped by pattern of NAP reported in left, right, upper, lower and central regions (max 5 regions) as follows: 1. none, 2. regional pain (RP) if 1 or 2 painful regions and 3. widespread pain (WSP) if 3-5 painful regions. We compared sociodemographic, RA clinical and patient reported outcome measures across patient pain groups at baseline as well as associations between pain patterns and achievement of ACR Boolean Remission and DAS Remission, with and without inclusion of patient global assessment at 6 and 12 months. Logistic regression was used to estimate age and sex, and multiple adjusted associations between RP and WSP with remission.

Results: Of 317 eligible patients, the mean (sd) age was 56 (14), baseline DAS28 was 4.9 (1.3); 199 (63%) were female, 225 (71%) met one or both 1987/2010 RA criteria and 287 (91%) were treated with csDMARDS +/- MTX. There were more patients with RP compared to WSP throughout the study period (Figure 1). Patients with no NAP (Gp 1) and RP (Gp 2) had lower scores on the RA-FQ, MDHAQ, and Fatigue. Similarly, patient pain ratings, PtGA, PHQ scores were lower in groups 1 and 2 vs group 3 (Table 1). PtGA was most discordant from MDGA in the WSP group. Depressive Symptoms were lowest in the no pain group as was the mean(sd) DAS28 at baseline (4.8 (1.4)). Patients with RP or no pain smoked less than those with WSP. Age/sex adjusted and fully adjusted logistic regression models predicting associations with remission are shown in table 2. Regional pain was significantly associated with reduced odds of Boolean remission at 6 months, and widespread pain tended to be associated with lower odds of Boolean remission at 6- and 12 months and lower odds of DAS28 remission at 12-months though the sample with widespread pain was small and confidence intervals were inconclusive.

Conclusion: Early RA patients frequently experienced regional and widespread non-articular pain, though regional pain is more common, perhaps reflecting strain injuries following a period of active RA with consequent sarcopenia. Results suggest non-articular pain tended towards fewer patients achieving remission. Clinicians should consider whether their patients have non-articular pain and address these separately to provide more holistic care. Non-articular pain may falsely lower remission status. Awareness of this is needed when implementing targeted care strategies.

ACR 2019 Pain Abstract_Table 1_Final

Table 1: Baseline Characteristics Across EIA Patients Reporting Absence of Non-Articular Pain, Non-Articular Regional Pain and Widespread Pain

ACR 2019 Pain Abstract_Figure 1

Figure 1. Proportion of EIA patients reporting regional and widespread pain over the first year of follow up

ACR 2019 Pain Abstract_Table 2_Final

Table 2: Logistic Regression Examining Associations Between Pain Pattern and Remission at 6- and 12-months Follow Up in Patients with EIA

Disclosure: V. Bykerk, Amgen, 5, Pfizer Pharmaceuticals, 5, Sanofi-Genzyme/Regeneron, 5, Schiper, 5, UCB, 5; O. Schieir, None; M. Valois, None; G. Boire, Abbvie, 2, Amgen, 2, 5, BMS, 2, 5, 8, Bristol-Myers Squibb, 2, 5, 8, Celgene, 5, Eli Lilly, 2, 5, Lilly, 2, 5, Merck, 2, 8, Novartis, 2, Pfizer, 2, 5, 8; G. Hazlewood, None; L. Bessette, AbbVie, 2, 5, 8, Abbvie, 2, 5, 8, Amgen, 2, 5, 8, Amgen, BMS, Janssen, Roche, UCB Pharma, AbbVie Inc, Pfizer, Merck, Celgene, Sanofi, Eli Lilly, and Novartis., 2, 5, 8, BMS, 2, 5, 8, Bristol-Myers Squibb, 2, 5, 8, Bristol-Myers-Squibb, 2, 5, 8, Celgene, 2, 5, 8, Eli Lilly, 2, 5, 8, Eli Lilly and Company, 2, 5, 8, Janssen, 2, 5, 8, Lilly, 2, 5, 8, Merck, 2, 5, 8, Novartis, 2, 5, 8, Pfizer, 2, 5, 8, Pfizer Inc, 2, 5, Roche, 2, 5, 8, Sanofi, 2, 5, 8, UCB, 2, 5, 8, UCB Pharma, 2, 5; C. Hitchon, Pfizer, 2, UCB, 2, UCB Canada, 2; D. Tin, None; C. Thorne, Abbvie, 2, 5, Amgen, 2, 5, CaREBiodam, 2, Celgene, 2, 5, Centocor, 5, Janssen, 5, Lilly, 5, Medexus/Medac, 5, 8, Merck, 5, Novartis, 2, 5, Pfizer, 2, 5, Sandoz, 5, Sanofi, 5; E. Keystone, Abbvie, 2, 5, 8, Amgen, 2, 5, 8, AstraZeneca, 5, Astra-Zeneca, 5, Biotest, 5, BMS, 2, 5, 8, Celltrion, 5, Crescendo, 5, Crescendo Bioscience, 5, F. Hoffmann-La Roche Inc, 2, 5, 8, Genentech, 5, Genentech Inc., 5, Genzyme, 5, Gilead, 2, 5, Gilead Sciences, Inc., 5, Janssen, 2, 5, 8, Lilly, 2, 5, 8, Merck, 5, 8, Pfizer, 2, 5, 8, Pfizer Pharmaceuticals, 2, 5, 8, Roche, 2, 5, 8, Sandoz, 5, Sanofi, 2, 5, 8, Sanofi-Aventis, 2, 8, UCB, 5, 8; J. Pope, AbbVie, 5, Abbvie, 5, Actelion, 5, Actellion, 5, Amgen, 2, 5, AstraZeneca, 2, Astra-Zeneca, 2, Bayer, 2, 5, BMS, 2, 5, Eicos Sciences, 5, Eli Lilly & Company, 5, Eli Lilly and Company, 5, EMERALD, 5, Emerald, 5, Genzyme, 5, Janssen, 5, Lilly, 5, Merck, 2, 5, Novartis, 5, Pfizer, 2, 5, Roche, 2, 5, Sandoz, 5, Sanofi, 5, Seattle Genetics, 2, UCB, 2, 5, 8; S. Bartlett, Abbie, 2, Abbvie, 2, 5, Bayer, 5, International Society of QOL Research, 6, Janssen, 5, 8, Lilly, 5, Merck, 5, 8, Novartis, 5, 8, Pfizer, 5, Pfizer Inc, 8, PROMIS International, 6, UCB, 5, 8; C. (CATCH) Investigators, Amgen, 2, Pfizer Canada, 2, AbbVie Corporation, 2, Medexus Inc., 2, Eli Lilly Canada, 2, Merck Canada, 2, Sandoz Canada Biopharmaceuticals, 2.

To cite this abstract in AMA style:

Bykerk V, Schieir O, Valois M, Boire G, Hazlewood G, Bessette L, Hitchon C, Tin D, Thorne C, Keystone E, Pope J, Bartlett S, (CATCH) Investigators C. Persistent and Non-Articular Regional and Widespread Pain Are Common in Early Rheumatoid Arthritis, Impacting Remission Rates and Reflected in Patient Global Scores [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/persistent-and-non-articular-regional-and-widespread-pain-are-common-in-early-rheumatoid-arthritis-impacting-remission-rates-and-reflected-in-patient-global-scores/. Accessed .

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