Abstract

Pain in rheumatology represents a frequent situation. For many years it has been considered as the prototypical nociceptive pain condition but recent findings may modify pathophysiological and treatment approaches.

1. Recent findings on pain mechanisms in rheumatic disorders:

• – in the periphery, bone has appeared as an important component of pain: imaging has demonstrated good correlations between bone abnormalities and pain intensity.

• – in the brain, arthritis pain induce changes and sensitization, with dysfunctional changes misdiagnosed as a neuropathic pain component.

• – arthritis pain is not a stable condition: exacerbations related to movement and at night could be related to different pathophysiological mechanisms.

2. Consequently, new therapeutic strategies have emerged, to be accepted by rheumatologists:

• – antidepressants may be effective in chronic joint pain, even without mood disorders.

• – NSAIDs have been limited in their use but the real place of old and recent opioids in this condition remains challenged.

• – the place of opioids has increased, even if efficacy of new opioids in rheumatological conditions is still controversial, while safety issues have been raised.

3. Biologic agents will be developed for joint pain:

• – New biological agents acting on NGF have demonstrated significant effect, but safety issues may limit their development.

• – Biologic agents developed in inflammatory rheumatisms like anti-TNF or anti-IL6 agents may exhibit peripheral but also central action.

4. Finally, adapted from RA treatment strategies, we may propose a new classification of analgesics:

• – Antinociceptive analgesics for acute flares, and changes related to motion or inflammation

• – -Pain Modifying Analgesics Agents (PMADs) for long term treatment, on chronic component.

In conclusion, pain management remains a challenge in rheumatology. We aim to demonstrate that all rheumatologists should be aware of recent findings in pain, both in pathophysiology and treatment. This may lead to new concepts of pain management in rheumatological conditions, for the benefit of our patients.