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SAT0550 Remaining Pain in Early RA Patients Treated with Methotrexate – Results from the Eira Cohort and the Swedish Rheumatology Quality Register
  1. R. Altawil1,
  2. S. Saevarsdottir1,
  3. S. Wedren1,
  4. L. Alfredsson2,
  5. L. Klareskog3,
  6. J. Lampa3
  1. 1Rheumalology, Medicin
  2. 2IMM
  3. 3Meds, Karolinska institutet, Stockholm, Sweden


Background Although treatment with methotrexate is efficient in decreasing inflammation and joint destruction in RA, several patients report remaining pain at follow-up, and the potential discrepancy between decrease in inflammation and pain needs to be explored further.

Objectives We investigated the frequency and possible predictors of remaining pain after 3 months treatment with MTX as the only DMARD treatment in early RA, with special focus on the patients who had a good clinical response to MTX.

Methods The study base was cases reported to the Environmental investigation of RA (EIRA) cohort 1996-2009 who had follow-up data in the Swedish Rheumatology Quality Register (1996-2010), a total of 1241 patients (69% women). Disease activity was measured with the 28-joint based disease activity score (DAS28) and the EULAR response criteria were used to evaluate clinical response to treatment. The primary endpoint was ‘remaining pain’ at the 3 months follow-up visit, defined as pain according to a 100 mm visual analog scale above 20 mm (VAS pain >20 mm), which has earlier been stated as a cutoff for patient reported significant pain (Ref Wolfe J Rheumatol 2007). The association between baseline parameters and remaining pain was evaluated by logistic regression and expressed as odds ratios (OR) with 95% confidence interval (95%CI), adjusted for age at onset/treatment start, gender and cigarette smoking status.

Results Median VAS-pain was 54 mm at baseline and 25 mm at the 3 months follow-up visit. Remaining pain was observed in 57% of all patients at the 3 months follow-up. The frequency of EULAR good/moderate/no response was 40%/38%/22% respectively, and in these response groups, the frequency of remaining pain was 29%/70%/83% respectively. In the EULAR good responder group (n=421), remaining pain was associated with more disability, measured as higher baseline HAQ (adjusted OR 2.2, 95%CI=1.4-3.4 per unit increase) and less inflammation, measured as lower baseline erythrocyte sedimentation rate, ESR (adjusted OR 0.81; 95%CI=0.70-0.93 per 10 mm increase). In line with this, patients who were EULAR good responders and had a remaining pain at follow-up exhibited lower ESR (p<0.02), and higher HAQ (p<0.02) at baseline compared to patients with less pain. Moreover, increase in VAS pain during the treatment period was observed in 19% of the whole cohort and frequencies of increased pain in the response groups were 9%/15%/45% respectively

Conclusions Majority of early RA patients starting methotrexate monotherapy at diagnosis have remaining pain after 3 months. Further, almost 1/5 of the patients actually exhibit increase in VAS pain during treatment. Despite good response to methotrexate, almost a third of those patients have remaining pain, and in moderate responders, more than two thirds of the patients have remaining pain. Remaining pain despite a good response to MTX is associated with more disability and less inflammation at baseline. These results are in line with the hypothesis that a subgroup of early RA patients exhibit pain that is not inflammatory mediated and where alternative treatment strategies can be discussed.

References Wolfe J Rheumatol 2007

Disclosure of Interest None Declared

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