Ian C. Scott

Background: Inflammatory arthritis (IA) is a common cause of chronic pain, which is often managed with long-term opioids and gabapentinoids (particularly in deprived areas) despite no evidence for efficacy. The extent to which efficacious, non-drug pain treatments are used is unclear. We addressed this by examining pain profiles and pain management in patients with IA from across the UK and exploring how they vary by deprivation. Methods: Two surveys were conducted - a Regional Hospital Survey (RHS), recruiting patients via Midlands’ rheumatology departments, and a National Patient Survey (NPS), recruiting patients from across the UK via online publicity, national patient organisations, and a research register. A cross-sectional questionnaire assessed pain and its care. Descriptive analyses summarised pain profiles and the prevalence of drug and non-drug pain management overall and across Index of Multiple Deprivation (IMD) quintiles. Logistic regression models examined associations between deprivation and opioid/gabapentinoid use. Results: RHS included 1,842 and NPS 1,049 patients (RHS/NPS mean ages 57.6/59.6 years; 64.6/84.7% female). High-impact chronic pain affected approximately one-half. Most reported being asked about pain regularly by clinicians (RHS 77.3/NPS 61.5%) but pain assessments were infrequently holistic. Opioid use was commonplace (RHS 43.5/NPS 47.8% used opioids in the past month). Obesity (RHS 38.8/NPS 35.3%) and persistent poor-quality sleep (RHS 68.9/NPS 74.4%) were prevalent; non-drug pain care, including weight/sleep management, was infrequent. Approximately half had seen a physiotherapist, and one third an occupational therapist/podiatrist post-IA diagnosis. High-impact chronic pain (65.9 vs. 46.0% RHS/61.3 vs. 48.0% NPS) and opioid use (48.5 vs. 39.4% RHS/51.9 vs. 41.6% NPS) were commoner in the most vs. least deprived IMD quintiles, with the latter association statistically significant in RHS (OR 1.45; 95% CI 1.07, 1.98), but not after adjusting for pain intensity. Pain-related factors like obesity were commoner in more deprived regions. Non-pharmacological pain management was similar across IMD quintiles. Conclusions: In patients with IA, chronic pain/opioid use are common, and holistic pain assessments/non-drug pain care are underused. Those in more deprived areas have more high-impact chronic pain. An increased focus on biopsychosocial IA pain care is needed, supported by policies to reduce health inequalities in pain.

Objectives: To report primary care prescribing rates of analgesics in people with PMR treated with glucocorticoids (GCs), overall and stratified by age, sex and deprivation. Methods: A sample of >43 000 individuals ≥50 years of age with a coded PMR diagnosis from January 2010 to March 2022 and prescribed GCs within 21 days of the first PMR diagnosis code was constructed in the Clinical Practice Research Datalink Aurum. Prescriptions for ‘all analgesics’, opioids, NSAIDs, gabapentinoids and amitriptyline were defined as prevalent (pre-PMR diagnosis), incident (at diagnosis) or late (post-diagnosis, still GC-treated) and reported overall and stratified by age/sex/deprivation. Results: While they were receiving GCs for PMR, 56.1% of participants were prescribed an analgesic. Opioids were the most frequently co-prescribed analgesics, followed by NSAIDs. Opioid prescribing was more common in females than males, at older ages and in more deprived areas. Amitriptyline and gabapentinoids were less commonly prescribed but followed the same sex and deprivation trends as opioids. NSAID prescribing was lower with older age, higher for males than females and did not vary with deprivation. Conclusion: Analgesics are frequently co-prescribed with GCs in people with PMR despite a lack of evidence of effectiveness and risks of adverse events. This shows an unmet need for better pain management in PMR. The identified variation in prescribing of opioids and gabapentinoids by gender/deprivation is consistent with prescribing data for the general population and people with other painful musculoskeletal conditions and suggests that psychosocial and cultural factors affect pain and pain management in patients being treated for PMR. This needs further exploration to address inequalities and reduce iatrogenic harm.

Pain is a frequent symptom in people with inflammatory arthritis (IA), which has substantial impact on their quality of life. Analyses of electronic health record data indicate that UK pain care in people with IA often involves prescribing long-term opioids and gabapentinoids, despite absent trial evidence for efficacy. Patient survey data suggest that non-pharmacological pain care with supportive trial evidence is underused. A UK-specific guideline on pain management for people with IA is required to address this. This comprehensive life-course guideline is the first British Society for Rheumatology Guideline to specifically address pain in people with IA. It provides evidence-based recommendations on how pain can be best managed in people with IA. It was developed using the methods outlined in the British Society for Rheumatology’s ‘Creating Clinical Guidelines’ protocol by a multidisciplinary Guideline Working Group, comprising healthcare professionals with expertise in paediatric and adult rheumatology and people with lived experience. By undertaking and considering the evidence from several systematic literature and umbrella reviews, 23 recommendations were developed. These address how pain should be assessed in people with IA alongside the role of the following treatments in IA pain management: DMARDs, glucocorticoids, analgesics, neuromodulators, exercise and physical activity, psychological interventions, ergonomic and orthotic interventions (excluding orthoses for foot pain), education, weight management and diet, addressing sleep problems, fatigue management, digital technologies and medical devices, complementary therapies, and support from others. An audit tool is provided to support the Guideline’s implementation, and key recommendations made for future research.

Objective: Many people with rheumatoid arthritis (RA) have chronic pain and flares of arthritis. The National RA Society has co‐produced a freely available online learning module with an NHS multidisciplinary rheumatology team to support people with self‐managing these RA impacts. This service evaluation assessed peoples' self‐reported knowledge and confidence in self‐managing pain/flares before and after accessing the module, the extent to which they used the module suggestions, and how they felt the module could be improved. Methods: A survey was sent via email in March 2024 to the 500 people completing the module who consented to contact for feedback. Survey questions covered: pain experience/management; knowledge/confidence on managing pain/flares; likelihood of trying module suggestions; and free‐text feedback. Descriptive statistics summarised responses. Fisher's exact tests compared Likert‐type responses for knowledge/confidence pre‐/post‐module. Results: One hundred and thirty four people completed the survey (27% response rate), of whom 98% experienced pain in the past 3 months and 36% reported ‘high impact’ chronic pain. More (95%) reported being ‘very/fairly/somewhat’ knowledgeable at managing pain after completing the module compared to before completing the module (62%; p < 0.01). For managing flares, these levels were 93% post‐module versus 52% pre‐module ( p < 0.01). Similar findings were seen for confidence. 90% reported themselves as ‘very/fairly/somewhat’ confident at managing pain post‐module versus 50% pre‐module ( p < 0.01). For managing flares, these levels were 90% post‐module versus 44% pre‐module ( p < 0.01). Most reported they were likely to try module suggestions. Conclusions: This freely available online digital information about pain/flares was appreciated by people with RA and helped them deal with these common condition aspects.

Objective: Polymyalgia rheumatica (PMR) is a common indication for long‐term glucocorticoid (GC) treatment. Bone‐protective and gastroprotective medications are recommended for those at high risk of adverse events from GCs, but no trials have evaluated their effectiveness in PMR. We describe bone‐protective and gastroprotective medicine prescribing in people with PMR and evaluate its impact on adverse GC outcomes using a target trial approach. Methods: A sample of >40,000 individuals aged ≥50 years with a coded PMR diagnosis from January 2010 to March 2022 who were prescribed GCs within 21 days of the first PMR diagnosis code was constructed in the Clinical Practice Research Datalink Aurum. Prescriptions were defined as prevalent (pre‐PMR diagnosis), incident (at diagnosis), or late (post diagnosis, still GC‐treated), reported stratified by age, sex, and deprivation. A target trial approach assessed the effects of (1) bisphosphonates on fragility fractures and (2) proton‐pump inhibitors/H ₂ receptor antagonists (PPIs/H ₂ RAs) on gastrointestinal (GI) ulceration/bleeding. Treatment effect, adjusted for confounders, was modeled using targeted maximum likelihood estimation. Results: 67.2% participants were coprescribed bisphosphonates and 78.6% were coprescribed PPIs/H ₂ RAs. Male patients and those in more deprived areas were less likely to receive bisphosphonates. 1.40% (95% confidence interval [CI] 1.10%–1.70%) of those prescribed bisphosphonates for 12 months versus 2.32% (95% CI 2.12%–2.52%) of those not prescribed bisphosphonates for 12 months experienced a fracture (risk difference 0.92% points [95% CI 0.56%–1.27%], number needed to treat 109). Prescribing gastroprotective medications was not associated with serious GI events. Conclusion: Rates of prescribing to mitigate GC harms are higher than previously reported. Bisphosphonates are associated with approximately one less fragility fracture per year for every 100 people treated. Gastro‐prophylaxis is not associated with reduced risk of GI ulceration/bleeding, suggesting potential to reduce prescribing for this indication. image

Objectives: While electronic patient-reported outcome measures (ePROMs) can facilitate innovative, holistic care for patients with inflammatory arthritis (IA), their implementation could inadvertently worsen health inequalities. This mixed methods study aimed to evaluate their feasibility and acceptability in routine care and how this varied by factors potentially impacting digital inclusion. Methods: Patients with IA were invited to complete ePROMs before/at their appointment on a National Health Service digital platform (Haywood Arthritis Portal). A cross-sectional survey and semi-structured interviews were conducted in consenting patients and healthcare professionals (HCPs). Acceptability was evaluated using the Theoretical Framework of Acceptability. Survey responses were summarised descriptively. Statistical tests assessed global acceptability responses in relation to factors associated with digital inclusivity. Interviews were analysed using the Rigorous and Accelerated Data Reduction technique. Quantitative and qualitative findings were triangulated. Results: A total of 336 patients and 11 HCPs were surveyed; 12 patients and 5 HCPs were interviewed. Patient surveys/interviews demonstrated high ePROMs acceptability (89% found ePROMs completely acceptable/acceptable; 89% felt they benefitted care). Acceptability was lower in those who were older (P < 0.001), lacked internet access (P = 0.009) and had low general/e-health literacy/digital skills (P < 0.001). The largest differences were in those with vs without essential digital skills (93.0% vs 42.9% rating ePROMs acceptable/completely acceptable). Patient and HCP interviews also demonstrated inclusivity concerns. All HCPs considered ePROMs acceptable. Conclusion: While using ePROMs is feasible and highly acceptable to patients with IA and HCPs, acceptability is lower in patients who are older, less health literate and with lower digital skills/access. These factors require careful consideration in ePROMs implementation to avoid worsening health inequalities.

Background: People with axial spondyloarthritis (axSpA) frequently experience increases in symptoms (flares) related to pain, stiffness and fatigue. Despite frequent use of the term ‘flare’ within axSpA, it is poorly defined and characterised. No widely accepted patient-reported outcome measure (PROM) exists that can identify axSpA flares or quantify their severity. However, the Evaluation of Ankylosing Spondylitis Quality of Life (EASiQoL) is a patient-derived axSpA-specific PROM with strong evidence of its ability to assess quality of life, an aspect affected by changes in symptoms. Objective: This study will look at the feasibility of identifying flares in people with axSpA through regular completion of an electronic (e) version of the EASiQoL. Methods: We will conduct a mixed-methods 12-month prospective cohort study. Up to 1000 people with axSpA from rheumatology departments and all members of the National Axial Spondyloarthritis Society will be invited to complete a baseline questionnaire containing several ePROMs, including the EASiQoL, via a bespoke online study portal. Of the estimated 1280 responders, all will receive e-mail reminders to complete monthly questionnaires for the following 10 months and a final 12-month follow-up questionnaire. Over the 12 months, a subsample of up to 40 participants who report a flare during this period will be invited to a qualitative interview. Their lived experience of ‘flare’ and how this was reflected in their EASiQoL scores will be explored. Potential impact: Collection of ePROM data sensitive to the presence of axSpA flares should provide readily accessible information to both patients and rheumatology teams to monitor disease course and develop more effective flare pathways in axSpA.

Background: Understanding the impact of intensive treatment on pain in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) is crucial to informing the application of evidence-based arthritis pain care. The impact of intensive treatment on inflammatory arthritis pain has received relatively limited attention. We addressed this through a detailed secondary analysis of three trials evaluating varying intensities of disease-modifying anti-rheumatic drug treatment. We considered a range of pain outcomes of clinical relevance to patients, including the achievement of mild endpoint pain scores and clinically-meaningful pain reductions. Methods: The trials comprised MIPA in PsA, CARDERA in early RA, and TITRATE in established RA. Pain was measured using a 100-mm pain intensity visual analogue scale (VAS). The impact of intensive treatment on (a) patients achieving “mild” endpoint pain intensity scores (of ≤ 34), b) mean changes in pain intensity scores, and (c) patients achieving ≥ 30% reductions in pain intensity scores was evaluated using t-tests, chi-squared tests, and regression models (with the latter adjusting for relevant potential confounding variables). Results: From MIPA, CARDERA, and TITRATE 128, 379, and 258 patients had endpoint outcome data available and were included in this secondary analysis. In all trials, significantly more patients achieved mild endpoint pain intensity scores with intensive vs. control treatment (MIPA 70% vs. 42%, P = 0.003; CARDERA 71% vs. 56%, P = 0.011; TITRATE 67% vs. 50%, P = 0.008). In the two trials employing the most intensive management strategies (CARDERA; TITRATE) overall reductions in pain scores were significantly greater (6.6 to 6.8 units in adjusted linear regression models), and significantly more achieved ≥ 30% reductions in pain with intensive vs. control treatment (adjusted logistic regression models: CARDERA odds ratio [OR] 1.9, P = 0.009; TITRATE OR 2.2, P = 0.002). Conclusions: Intensive treatment is an important component of improving pain in patients with active RA and PsA. Our findings support EULAR guidance that optimising disease activity is crucial for pain control. As approximately one third of patients receiving active treatment had moderate/high endpoint pain intensity levels across trials, additional pain management strategies that complement intensive treatment are needed. Trial registration: Current Controlled Trials CARDERA ISRCTN32484878 (25/10/2000), MIPA ISRCTN54376151 (04/02/2002), and TITRATE ISRCTN70160382 (16/1/2014).

As many patients with inflammatory arthritis (IA) have chronic pain, understanding how to best assess and manage pain in IA is a priority. Comorbid depression is prevalent in adults with IA, affecting 15% to 39% of people. Although pain and depression are thought to be associated in IA, this concept is largely based on cross‐sectional data. To better understand potential causality, longitudinal studies are required. This narrative review examines the relationship between pain and depression in patients with IA participating in observational longitudinal studies (spanning association strengths, direction of effect, and causal factors) and summarizes the literature on causal pathways in general populations alongside guideline recommendations/systematic reviews on assessing pain/depression in IA. Fourteen longitudinal studies in IA largely indicate an association between pain and depression, albeit with a small‐to‐modest effect size and a focus on pain intensity. This relationship appears to be bidirectional. Evidence on causal pathways is sparse in IA and limited in non‐IA populations (with structural/function brain changes, altered sensory/pain thresholds, and sleep disturbance implicated) highlighting a need for further research. Although many patient‐reported outcome measures exist to assess pain and depression in IA, evidence for their psychometric properties is often limited, and IA guidelines offer incomplete advice on pain/depression assessment. A simple approach of using a single‐item pain intensity score (eg, a Numeric Rating Scale, which has strong clinimetric properties) in routine IA consultations, with screening for depression where relevant, appears appropriate. Further research is needed to understand how this could be achieved in different health care settings. image