Neuropathic pain: is it an underestimated symptom in systemic sclerosis?

Annual trends in pain management modalities in patients with newly diagnosed autoimmune rheumatic diseases in the USA from 2007 to 2021: an administrative claims-based study

BACKGROUND

Autoimmune rheumatic diseases have distinct pathogenic mechanisms and are causes of disability and increased mortality worldwide. In this study, we aimed to examine annual trends in pain management modalities among patients with autoimmune rheumatic diseases.

METHODS

We identified newly diagnosed patients with ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, Sjögren's syndrome, systemic sclerosis, or systemic lupus erythematosus (SLE) in the Merative Marketscan Research Databases from 2007 to 2021. The database includes deidentified inpatient and outpatient health encounters with employment-sponsored health insurance claims in the USA. We found minimal occurrences of multiple overlapping conditions and included only the initial recorded diagnosis for each patient. We determined the annual incidence of patients treated with opioids, anticonvulsants, antidepressants, skeletal muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, and physical therapy in the year following diagnosis. Logistic regression was used to estimate the association between calendar year and outcomes, adjusted for age, sex, and region.

FINDINGS

We included 141 962 patients: 10 927 with ankylosing spondylitis, 21 438 with psoriatic arthritis, 71 393 with rheumatoid arthritis, 16 718 with Sjögren's syndrome, 18 018 with SLE, and 3468 with systemic sclerosis. 107 475 (75·7%) were women and 34 487 (24·3%) were men. Overall, the incidence of opioid use increased annually until 2014 by 4% (adjusted odds ratio [aOR] 1·04 [95% CI 1·03-1·04]) and decreased annually by 15% after 2014 (0·85 [0·84-0·86]). The incidence of physical therapy use increased annually by 5% until 2014 (aOR 1·05 [95% CI 1·04-1·06]), with a slight decrease annually by 1% after 2014 (0·99 [0·98-1·00]). The incidence of anticonvulsant use increased annually by 7% until 2014 (aOR 1·07 [95% CI 1·07-1·08]) and did not significantly change after 2014 (1·00 [0·99-1·00]). Before 2014, the incidence of NSAIDs use increased by 2% annually (aOR 1·02 [95% CI 1·02-1·03]); however, after 2014, the incidence decreased annually by 5% (0·95 [0·95-0·96]). These trends did not differ by sex except for NSAID use before 2014 (pinteraction=0·02) and topical analgesic use after 2014 (pinteraction=0·0100).

INTERPRETATION

Since 2014, the use of non-opioid pain management modalities has increased or stabilised, whereas opioid and NSAID use has declined. Future studies are needed to evaluate the effectiveness of these changes, and the effects they have had on outcomes such as quality of life, disability, and function.

FUNDING

National Institute of Arthritis and Musculoskeletal and Skin Diseases.

The Emerging Challenge of Pain in Systemic Sclerosis: Similarity to the Pain Experience Reported by Sjőgren's Syndrome Patients

In order to evaluate the importance of pain in systemic sclerosis (SSc), the characteristics of pain reported by patients with SSc were analyzed and compared with the characteristics of pain reported by patients with primary Sjőgren's syndrome (pSS). Pain was reported by 56 patients (80%) in a group of 70 patients with SSc and by 25 patients (78%) in a group of 32 patients with pSS. Pain severity was assessed by the Pain Rating Index (PRI) and the Present Pain Intensity (PPI) of the McGill Pain Questionnaire (MPQ) and by values obtained by a visual analog scale (VAS) indicating the intensity of pain felt in the moment of the examination and the intensity of pain felt in the week preceding the moment of the examination. No significant difference was detected in the comparison of mean values of pain indices between patients with SSc and patients with pSS and in the comparison among subgroups of patients with SSc. The data indicate that pain is a frequent and important cause of suffering in SSc as in other chronic diseases. The association of different methods may be especially useful to obtain a careful evaluation of pain in clinical research.

Neurological and electroneurography findings in patients with systemic sclerosis and symptoms of neuropathic pain in extremities

OBJECTIVE

To analyze neurological and electroneurography (ENG) findings in patients with systemic sclerosis (SSc) and symptoms of neuropathic pain in upper and lower extremities.

PATIENTS AND METHODS

Using the PainDetect questionnaire, 42 consecutive patients with SSc (38 women and 4 men) were screened for the presence of neuropathic pain in upper and/or lower extremities. Patients with previously diagnosed diabetes or other metabolic diseases, malignancy, other autoimmune disorders, or any neurological or psychiatric disease, were not included. Neurological examination, ENG, and laboratory analyses (glycated hemoglobin-HbA₁C, and vitamin B12) were performed in SSc patients with neuropathic pain in extremities. Methods of descriptive statistics were used to summarize the data.

RESULTS

Eleven patients (26.2%) had significant symptoms of neuropathic pain in extremities. Neurological examination indicated polyneuropathy in 10/11 (90.9%) of patients. Symmetrical hyperesthesia in the lower and/or upper extremities was found in ten patients. Symmetrical hyporeflexia was found in 7/11 (63.6%) of patients in the arms, and 6/11 (54.4%) of patients in the legs. Proprioception was diminished in 3/11 (27.3%), whilst pallhypesthesia was present in all patients. However, polyneuropathy could be confirmed by ENG only in four out of ten SSc patients, who had typical neurological findings for polyneuropathy. Hypoesthesia in a specific lumbar root dermatome, suggesting radiculopathy, was found in 6/11 (54.5%) of patients. Asymmetrical hyporeflexia was noticed in 2/11 (18.1%) of patients in the lower limbs. Seven patients (63.6%) had signs of radiculopathy in at least one root dermatome on ENG.

CONCLUSION

A significant number of SSc patients with neuropathic pain in the upper and/or lower extremities have symptoms and signs of polyneuropathy undetectable by ENG, which indirectly suggests the presence of small-fiber polyneuropathy in these patients. In some patients, radiculopathy cannot be excluded as possible co-morbid non-scleroderma condition associated with neuropathic pain.

Spezielle Schmerztherapie bei rheumatischen Erkrankungen

Schmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.

[Peripheral nerve involvement in rheumatic diseases]

Peripheral neuropathies are probably an under-diagnosed complication of many rheumatic diseases. In some cases they take a mild clinical course, in others they cause severe impairment of patients' quality of life. A precise diagnosis and etiological classification are of major importance for successful treatment and prognosis of peripheral neuropathies. A detailed patient history and physical examination are the foundation of every diagnostic approach. Electrophysiological studies are obligatory when peripheral neuropathy is suspected, whereas nerve or nerve-muscle biopsies are indicated only in selected cases. Therapeutic approaches are often complicated by a lack of evidence. They correspond to frequently tested immunosuppressive treatment of the underlying disease, such as glucocorticoids, cyclophosphamide, mycophenolate mofetil and intravenous immunoglobulins and are based on the symptomatic pain treatment of other neuropathies. As first-line treatment gabapentin, pregabalin, duloxetine, venlafaxine and tricyclic antidepressants are frequently used.