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Ramírez Medina CR, Feng M, Huang YT, Jenkins DA, Jani M. Machine learning identifies risk factors associated with long-term opioid use in fibromyalgia patients newly initiated on an opioid. RMD Open 2024; 10:e004232. [PMID: 38772680 DOI: 10.1136/rmdopen-2024-004232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Long-term opioid use is associated with several adverse outcomes. Identifying factors associated with long-term opioid use is the first step in developing targeted interventions. The aim of this study was to evaluate risk factors in fibromyalgia patients newly initiated on opioids using machine learning. METHODS A retrospective cohort study was conducted using a nationally representative primary care dataset from the UK, from the Clinical Research Practice Datalink. Fibromyalgia patients without prior cancer who were new opioid users were included. Logistic regression, a random forest model and Boruta feature selection were used to identify risk factors related to long-term opioid use. Adjusted ORs (aORs) and feature importance scores were calculated to gauge the strength of these associations. RESULTS In this study, 28 552 fibromyalgia patients initiating opioids were identified of which 7369 patients (26%) had long-term opioid use. High initial opioid dose (aOR: 31.96, mean decrease accuracy (MDA) 135), history of self-harm (aOR: 2.01, MDA 44), obesity (aOR: 2.43, MDA 36), high deprivation (aOR: 2.00, MDA 31) and substance use disorder (aOR: 2.08, MDA 25) were the factors most strongly associated with long-term use. CONCLUSIONS High dose of initial opioid prescription, a history of self-harm, obesity, high deprivation, substance use disorder and age were associated with long-term opioid use. This study underscores the importance of recognising these individual risk factors in fibromyalgia patients to better navigate the complexities of opioid use and facilitate patient-centred care.
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Affiliation(s)
- Carlos Raúl Ramírez Medina
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Mengyu Feng
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, UK
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Scott IC, Whittle R, Bailey J, Twohig H, Hider SL, Mallen CD, Muller S, Jordan KP. Analgesic prescribing in patients with inflammatory arthritis in England: observational studies in the Clinical Practice Research Datalink. Rheumatology (Oxford) 2024; 63:1672-1681. [PMID: 37822018 PMCID: PMC11147543 DOI: 10.1093/rheumatology/kead463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 08/18/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVES Despite little evidence that analgesics are effective in inflammatory arthritis (IA), studies report substantial opioid prescribing. The extent this applies to other analgesics is uncertain. We undertook a comprehensive evaluation of analgesic prescribing in patients with IA in the Clinical Practice Research Datalink Aurum to evaluate this. METHODS From 2004 to 2020, cross-sectional analyses evaluated analgesic prescription annual prevalence in RA, PsA and axial spondyloarthritis (axSpA), stratified by age, sex, ethnicity, deprivation and geography. Joinpoint regression evaluated temporal prescribing trends. Cohort studies determined prognostic factors at diagnosis for chronic analgesic prescriptions using Cox proportional hazards models. RESULTS Analgesic prescribing declined over time but remained common: 2004 and 2020 IA prescription prevalence was 84.2/100 person-years (PY) (95% CI 83.9, 84.5) and 64.5/100 PY (64.2, 64.8), respectively. In 2004, NSAIDs were most prescribed (56.1/100 PY; 55.8, 56.5), falling over time. Opioids were most prescribed in 2020 (39.0/100 PY; 38.7, 39.2). Gabapentinoid prescribing increased: 2004 prevalence 1.1/100 PY (1.0, 1.2); 2020 prevalence 9.9/100 PY (9.7, 10.0). Most opioid prescriptions were chronic (2020 prevalence 23.4/100 PY [23.2, 23.6]). Non-NSAID analgesic prescribing was commoner in RA, older people, females and deprived areas/northern England. Conversely, NSAID prescribing was commoner in axSpA/males, varying little by deprivation/geography. Peri-diagnosis was high-risk for starting chronic opioid/NSAID prescriptions. Prognostic factors for chronic opioid/gabapentinoid and NSAID prescriptions differed, with NSAIDs having no consistently significant association with deprivation (unlike opioids/gabapentinoids). CONCLUSION IA analgesic prescribing of all classes is widespread. This is neither evidence-based nor in line with guidelines. Peri-diagnosis is an opportune moment to reduce chronic analgesic prescribing.
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Affiliation(s)
- Ian C Scott
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Rebecca Whittle
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - James Bailey
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Helen Twohig
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Samantha L Hider
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire, UK
| | - Sara Muller
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Kelvin P Jordan
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
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3
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Luo Q, Zhang Y, Yang X, Qin L, Wang H. Hypertension in connective tissue disease. J Hum Hypertens 2024; 38:19-28. [PMID: 35505225 DOI: 10.1038/s41371-022-00696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 02/23/2022] [Accepted: 04/12/2022] [Indexed: 11/10/2022]
Abstract
It is well documented that connective tissue disease (CTD) is a type of autoimmune disease characterized by chronic inflammation, which can occur across various organ systems throughout the whole body. Although the clinical manifestations of CTD are different, studies have shown that different CTD diseases have similar pathogenesis, implying that different CTD diseases may have similar clinical outcomes. Recent population-based studies have demonstrated an increased risk of cardiovascular disease (CVD) in patients with CTD compared with the control group, which is partially attributed to traditional cardiovascular risk factors, such as hypertension (HT), and that controlling the patients' blood pressure (BP) still constitutes one of the most effective means to prevent CVD. Although many studies have shown that the prevalence of HT in patients with CTD is higher than that in the general population, there is a lack of adequate data on the possible pathogenesis of HT. Also, the factors that promote the rise of BP, especially the relationship between connective tissue disease- hypertension (CTD-HT) and traditional cardiovascular risk factors (aging, sex, race, dyslipidemia, diabetes mellitus, smoking, obesity, etc.), have not been fully confirmed. In this review, we explore the mechanisms that might lead to elevated BP in patients with CTD and the factors that contribute to elevated BP and the management of CTD-HT, and we focus on whether traditional cardiovascular risk factors, the disease, and the presence of related therapeutic drugs are associated with an increased risk of HT in patients with CTD.
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Affiliation(s)
- Qiang Luo
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Yiwen Zhang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Xiaoqian Yang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Li Qin
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China
| | - Han Wang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St., Chengdu, Sichuan, China.
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Salis Z, Gallego B, Sainsbury A. Researchers in rheumatology should avoid categorization of continuous predictor variables. BMC Med Res Methodol 2023; 23:104. [PMID: 37101144 PMCID: PMC10134601 DOI: 10.1186/s12874-023-01926-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Rheumatology researchers often categorize continuous predictor variables. We aimed to show how this practice may alter results from observational studies in rheumatology. METHODS We conducted and compared the results of two analyses of the association between our predictor variable (percentage change in body mass index [BMI] from baseline to four years) and two outcome variable domains of structure and pain in knee and hip osteoarthritis. These two outcome variable domains covered 26 different outcomes for knee and hip combined. In the first analysis (categorical analysis), percentage change in BMI was categorized as ≥ 5% decrease in BMI, < 5% change in BMI, and ≥ 5% increase in BMI, while in the second analysis (continuous analysis), it was left as a continuous variable. In both analyses (categorical and continuous), we used generalized estimating equations with a logistic link function to investigate the association between the percentage change in BMI and the outcomes. RESULTS For eight of the 26 investigated outcomes (31%), the results from the categorical analyses were different from the results from the continuous analyses. These differences were of three types: 1) for six of these eight outcomes, while the continuous analyses revealed associations in both directions (i.e., a decrease in BMI had one effect, while an increase in BMI had the opposite effect), the categorical analyses showed associations only in one direction of BMI change, not both; 2) for another one of these eight outcomes, the categorical analyses suggested an association with change in BMI, while this association was not shown in the continuous analyses (this is potentially a false positive association); 3) for the last of the eight outcomes, the continuous analyses suggested an association of change in BMI, while this association was not shown in the categorical analyses (this is potentially a false negative association). CONCLUSIONS Categorization of continuous predictor variables alters the results of analyses and could lead to different conclusions; therefore, researchers in rheumatology should avoid it.
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Affiliation(s)
- Zubeyir Salis
- The University of New South Wales, Centre for Big Data Research in Health, Kensington, NSW, Australia
| | - Blanca Gallego
- The University of New South Wales, Centre for Big Data Research in Health, Kensington, NSW, Australia
| | - Amanda Sainsbury
- School of Human Sciences, The University of Western Australia, Crawley, Perth, WA, 6009, Australia.
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5
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Wheeler AM, Roul P, Yang Y, Brittan KM, Sayles H, Singh N, Sauer BC, Cannon GW, Baker JF, Mikuls TR, England BR. Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:785-792. [PMID: 35612872 PMCID: PMC9532468 DOI: 10.1002/acr.24890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/21/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA). METHODS We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system. RESULTS We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]). CONCLUSION RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.
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Affiliation(s)
- Austin M. Wheeler
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Kaitlyn M. Brittan
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Harlan Sayles
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | | | - Brian C. Sauer
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Grant W. Cannon
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania, Philadelphia, PA
| | - Ted R. Mikuls
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Bryant R. England
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Ranganath VK, La Cava A, Vangala S, Brook J, Kermani TA, Furst DE, Taylor M, Kaeley GS, Carpenter C, Elashoff DA, Li Z. Improved outcomes in rheumatoid arthritis with obesity after a weight loss intervention: randomized trial. Rheumatology (Oxford) 2023; 62:565-574. [PMID: 35640116 DOI: 10.1093/rheumatology/keac307] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/14/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine whether a weight loss intervention programme improves RA disease activity and/or musculoskeletal ultrasound synovitis measures in obese RA patients. METHODS We conducted a proof-of-concept, 12-week, single-blind, randomized controlled trial of obese RA patients (BMI ≥ 30) with 28-joint DAS (DAS28) ≥ 3.2 and with evidence of power Doppler synovitis. Forty patients were randomized to the diet intervention (n = 20) or control group (n = 20). Diet intervention consisted of a hypocaloric diet of 1000-1500 kcal/day and high protein meal replacements. Co-primary outcomes included change in DAS28 and power Doppler ultrasound (PDUS)-34. Clinical disease activity, imaging, biomarkers, adipokines and patient-reported outcomes were monitored throughout the trial. Recruitment terminated early. All analyses were based on intent-to-treat for a significance level of 0.05. RESULTS The diet intervention group lost an average 9.5 kg/patient, while the control group lost 0.5 kg (P < 0.001). Routine Assessment of Patient Index Data 3 (RAPID3) improved, serum leptin decreased and serum adiponectin increased significantly within the diet group and between the groups (all P < 0.03). DAS28 decreased, 5.2 to 4.2, within the diet group (P < 0.001; -0.51 [95% CI -1.01, 0.00], P = 0.056, between groups). HAQ-Disability Index (HAQ-DI) improved significantly within the diet group (P < 0.04; P = 0.065 between group). Ultrasound measures and the multi-biomarker disease activity score did not differ between groups (PDUS-34 -2.0 [95% CI -7.00, 3.1], P = 0.46 between groups). CONCLUSION Obese RA patients on the diet intervention achieved weight loss. There were significant between group improvements for RAPID3, adiponectin and leptin levels, and positive trends for DAS28 and HAQ-DI. Longer-term, larger weight loss studies are needed to validate these findings, and will allow for further investigative work to improve the clinical management of obese RA patients. TRIAL REGISTRATION ClinicalTrials.gov, https://clinicaltrials.gov, NCT02881307.
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Affiliation(s)
- Veena K Ranganath
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Antonio La Cava
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Jenny Brook
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Tanaz A Kermani
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Daniel E Furst
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Florence, Florence, Italy
| | - Mihaela Taylor
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Gurjit S Kaeley
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Catherine Carpenter
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - David A Elashoff
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Zhaoping Li
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
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Rheumatoide Arthritis: Adipositas begünstigt
Opiatanwendung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1693-6342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Eine rheumatoide Arthritis (RA) prädisponiert für eine
Langzeitbehandlung mit Opiaten. Besonders gefährdet sind
diesbezüglich Patientinnen und Patienten mit einer hohen
Krankheitsaktivität, stärkeren Einschränkungen sowie
begleitender Antidepressivaeinnahme. Ob auch eine Adipositas eine chronische
Opiatanwendung begünstigt, untersuchte nun ein US-Forscherteam mithilfe
einer registerbasierten Studie.
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Anastasiou C, Yazdany J. Review of publications evaluating opioid use in patients with inflammatory rheumatic disease. Curr Opin Rheumatol 2022; 34:95-102. [PMID: 35044328 PMCID: PMC8974237 DOI: 10.1097/bor.0000000000000868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW This article discusses publications assessing the prevalence, efficacy, and safety of opioid analgesics in patients with rheumatic diseases, including rheumatoid arthritis, systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, and systemic sclerosis. RECENT FINDINGS Recent studies show long-term opioid use is common in patients with inflammatory rheumatic disease. We did not find any studies demonstrating improved function or pain control with long-term opioid use in people with rheumatic diseases. Some data shows potential adverse effects including increased risk for fractures and opioid poisoning hospitalizations. There is evidence demonstrating an association of opioid use with mental health disorders, fibromyalgia, obesity, and disability, although causative links have not been established. Only minimal reductions in opioid use were observed after initiation of biologic disease modifying antirheumatic drugs (DMARDs). Studies have shown delayed DMARD initiation and reduced DMARD use in patients on opioids, raising concerns that these analgesics may delay care or initially mask symptoms of active disease. SUMMARY Available literature highlights high levels of opioid use in people with rheumatic disease, without scientific evidence to support efficacy for chronic pain control and increasing evidence of adverse events. These findings strongly suggest that opioids do not have a routine role in the chronic management of inflammatory rheumatic diseases.
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Affiliation(s)
- Christine Anastasiou
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, California, USA
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Abstract
PURPOSE OF REVIEW Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms. RECENT FINDINGS At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA. SUMMARY Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.
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Affiliation(s)
| | - Beth I Wallace
- University of Michigan Medical School
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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