Rheumatoid arthritis (RA) is a painful condition on its own thanks to the chronic inflammation of joints in the hands and feet. Despite the help of medication to control inflammation, many RA patients still report experiencing neuropathic pain — even while in remission.

Researchers from the University of Twente in the Netherlands used the painDETECT screening tool to evaluate neuropathic-like pain symptoms in 159 patients (mean age = 57.2 years) with RA, 74.8% of whom were in remission, and 13.2% had low disease activity. Among the patients, about 44% reported clinically-significant pain in the past four weeks, with an average pain score of ≥4 on the 10-point painDETECT scale.1

According to the painDETECT tool, 27 patients (17%) likely had neuropathic pain and 34 patients (21.4%) possibly had neuropathic pain. Those with likely or possible neuropathic pain reported more severe pain, and were also more likely to meet diagnostic criteria for fibromyalgia, use analgesics, have more tender joints, and have a worse physical and mental health status measured by the Short-Form health survey. After controlling for pain severity, physical and mental health status was still significantly associated with neuropathic pain symptoms.

The results from the study indicate that there is a possible non-inflammatory pain component present in RA, which is typically brought into remission with anti-inflammatory drugs. However, these treatments, which can range from DMARDs and glucocorticoids to expensive biologicals, do little for neuropathic pain, which would be better controlled with neuromodulators and some antidepressants, the researchers suggested.


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“If effective in RA patients with neuropathic pain-like symptoms who fail to reach remission, these therapies could be more cost-effective and, more importantly, result in a better quality of life than current treatment strategies,” they wrote.

Summary and Clinical Applicability

The natural course of RA includes both periods of exacerbations (also known as flares) and reductions of disease severity. This study suggests that even during disease remission, a number patients exhibit neuropathic pain symptoms.

Any evaluation of pain should include a determination if pain is either nociceptive or neuropathic. There is general consensus that the initial treatment of neuropathic pain involves antidepressants like tricyclic antidepressants (TCAs) or dual reuptake inhibitors of serotonin and norepinephrine (SNRIs) or calcium channel alpha 2-delta ligands.2

Reference

1. Koop SMW, ten Klooster PM, Vonkeman HE, Steunebrink LMM, van de Laar MAFJ. Neuropathic-like pain features and cross-sectional associations in rheumatoid arthritis. Arthritis Research & Therapy. 2015;17(1):237. doi:10.1186/s13075-015-0761-8.

2. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015; 14:162.

This article originally appeared on Neurology Advisor