McWilliams Daniel F, Rahman Shimin, James Richard J E, Ferguson Eamonn, Kiely Patrick D W, Young Adam, Walsh David A
1Pain Centre Versus Arthritis, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.
2Division of ROD, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB UK.
BMC Rheumatol. 2019 Nov 18;3:49. doi: 10.1186/s41927-019-0100-9. eCollection 2019.
RA flares are common and disabling. They are described in terms of worsening inflammation but pain and inflammation are often discordant. To inform treatment decisions, we investigated whether inflammatory and pain flares are discrete entities.
People from the Early RA Network (ERAN) cohort were assessed annually up to 11 years after presentation ( = 719, 3703 person-years of follow up). Flare events were defined in 2 different ways that were analysed in parallel; DAS28 or Pain Flares. DAS28 Flares satisfied OMERACT flare criteria of increases in DAS28 since the previous assessment (≥1.2 points if active RA or ≥ 0.6 points if inactive RA). A ≥ 4.8-point worsening of SF36-Bodily Pain score defined Pain Flares. The first documented episode of each of DAS28 and Pain Flare in each person was analysed. Subgroups within DAS28 and Pain Flares were determined using Latent Class Analysis. Clinical course was compared between flare subgroups.
DAS28 (45%) and Pain Flares (52%) were each common but usually discordant, with 60% of participants in DAS28 Flare not concurrently in Pain Flare, and 64% of those in Pain Flare not concurrently in DAS28 Flare. Three discrete DAS28 Flare subgroups were identified. One was characterised by increases in tender/swollen joint counts (14.4%), a second by increases in symptoms (13.1%), and a third displayed lower flare severity (72.5%). Two discrete Pain Flare subgroups were identified. One occurred following low disease activity and symptoms (88.6%), and the other occurred on the background of ongoing active disease and pain (11.4%). Despite the observed differences between DAS28 and Pain Flares, each was associated with increased disability which persisted beyond the flare episode.
Flares are both common and heterogeneous in people with RA. Furthermore our findings indicate that for some patients there is a discordance between inflammation and pain in flare events. This discrete flare subgroups might reflect different underlying inflammation and pain mechanisms. Treatments addressing different mechanisms might be required to reduce persistent disability after DAS28 and Pain Flares.
类风湿关节炎（RA）病情发作很常见且会导致功能障碍。病情发作通常根据炎症加重来描述，但疼痛和炎症常常不一致。为指导治疗决策，我们研究了炎症发作和疼痛发作是否为不同的情况。
对早期类风湿关节炎网络（ERAN）队列中的患者进行长达11年的年度评估（n = 719，随访3703人年）。发作事件通过两种不同方式定义并平行分析；分别为疾病活动评分28（DAS28）发作或疼痛发作。DAS28发作符合OMERACT发作标准，即自上次评估以来DAS28升高（如果是活动期RA则≥1.2分，如果是非活动期RA则≥0.6分）。SF36身体疼痛评分恶化≥4.8分定义为疼痛发作。分析了每个人首次记录的DAS28发作和疼痛发作事件。使用潜在类别分析确定DAS28发作和疼痛发作中的亚组。比较发作亚组之间的临床病程。
DAS28发作（45%）和疼痛发作（52%）都很常见，但通常不一致，60%的DAS28发作参与者同时没有疼痛发作，64%的疼痛发作参与者同时没有DAS28发作。确定了三个不同的DAS28发作亚组。一个以压痛/肿胀关节计数增加为特征（14.4%），第二个以症状增加为特征（13.1%），第三个发作严重程度较低（72.5%）。确定了两个不同的疼痛发作亚组。一个发生在疾病活动度低和症状出现之后（88.6%），另一个发生在持续的疾病活动和疼痛背景下（11.4%）。尽管观察到DAS28发作和疼痛发作之间存在差异，但两者都与残疾增加有关，且这种残疾在发作事件后仍持续存在。
RA患者的病情发作既常见又具有异质性。此外，我们的研究结果表明，对于一些患者，发作事件中的炎症和疼痛之间存在不一致。这种不同的发作亚组可能反映了不同的潜在炎症和疼痛机制。可能需要针对不同机制的治疗来减少DAS28发作和疼痛发作后的持续性残疾。
