Key clinical point: Current treatment strategies for patients with early methotrexate-refractory RA with the addition of either a tumor necrosis factor inhibitor or sulfasalazine plus hydroxychloroquine are insufficient to prevent development of inflammation-independent pain.

Major finding: RA patients who took biologic combination therapy had 32% lower risk for unacceptable pain (rated at >40 mm on a 0- to 100-mm visual analog scale) at 21 months, but they still had no difference from patients taking triple therapy in the rate of pain described as refractory, or unacceptable despite inflammation control (C-reactive protein <10 mg/L).

Study details: A post hoc analysis of 164 patients with early RA from the open-label, randomized, controlled SWEFOT trial who underwent 21 months of follow-up.

Disclosures: The original SWEFOT study was supported in part by a grant from the Swedish Rheumatism Association, and in part by an annual unrestricted grant from Schering-Plough Sweden (now Merck Sharp & Dohme). The post hoc analysis was supported by Lund University and the Kockska Foundation, the Swedish Research Council, and the Stockholm County Council. Two authors disclosed financial relationships with multiple pharmaceutical companies.

Commentary

“The original SWEFOT study examined clinical and radiographic outcomes of patients with early RA treated with methotrexate, sulfasalazine, and hydroxychloroquine vs methotrexate and infliximab; in this study, researchers differentiated between acceptable pain, inflammatory pain (defined by VAS >40 and CRP>10 mg/dL), and refractory pain.

As expected, pain levels decreased in both groups with treatment over the course of 21 months, but about 1/3 of patients in both groups reported refractory pain, defined as VAS > 40 with CRP <10 mg/dL). These important findings bear out experiences of persistent pain in RA patients, but do not necessarily tell us that refractory pain is strictly non-inflammatory or unrelated to disease activity, given the tracking of CRP with various therapies. A CRP-independent measure or tracking of individual patients’ pain would help to confirm these findings.”

Arundathi Jayatilleke, MD

Lewis Katz School of Medicine, Temple University