Rheumatoid arthritis is the most common autoimmune inflammatory arthropathy, affecting 0.5 to 1% of the adult population in developed countries and characterized primarily by symmetrical involvement of the small joints of the hands and feet.
World Arthritis Day is a global event held every year on October 12 to raise awareness about rheumatic and musculoskeletal diseases, their impact on people’s lives, educate the public about symptoms, early recognition and timely diagnosis, all with the aim of preventing reducing the risk of long-term complications. The focus of World Arthritis Day is to provide greater support and improve treatment options for people living with rheumatic and musculoskeletal diseases.
Rheumatic diseases represent a significant part of human pathology. They are most often chronic and significantly impair quality of life and work productivity. Hence, they have not only a health, but also a major socio-economic impact.
Inflammatory Arthritis (IA) comprises a group of chronic inflammatory joint diseases characterized by joint pain, swelling, warmth, and morning stiffness lasting longer than one hour. Many inflammatory arthritis are systemic diseases and may also present with inflammatory manifestations affecting other tissues and organs, including skin rashes and lesions, eye inflammation, hair loss, fever, and other inflammatory symptoms. Joint inflammation leads to joint damage; therefore, these conditions represent a major challenge for modern medicine because they result in significant disability and reduced quality of life. The most common autoimmune inflammatory joint diseases include rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA).
Rheumatoid arthritis is the most common autoimmune inflammatory arthropathy, affecting 0.5 to 1% of the adult population in developed countries and mainly characterized by symmetrical involvement of the joints of the extremities. Ankylosing spondylitis occurs in 0.1% to 1.4% of the adult population, and psoriatic arthritis is the most common seronegative inflammatory arthropathy, occurring in 5-30% of patients with psoriasis. The high prevalence of these diseases and the fact that they represent a large economic burden on society, not only due to the direct costs of treatment, but also due to the disability they cause.
A study reveals that 49% of patients with rheumatoid arthritis, 41% of those with ankylosing spondylitis and 39% of patients with psoriatic arthritis have difficulty performing their usual daily activities. Modern medicine offers a wide range of pharmacological treatments, including conventional disease-modifying drugs as well as newer biological and targeted therapies. The primary goal of treatment is to achieve remission or low disease activity, both clinically and according to laboratory findings. It has been demonstrated that the introduction of disease-modifying therapy and biologic therapies in patients with RA reduces disease activity, slows joint damage and disability, and improves the ability to perform everyday activities.
Osteoarthritis (OA) is a degenerative joint disease that affects the cartilage and surrounding tissues. Over 10% of the world’s population has clinical symptoms of osteoarthritis, and this percentage increases with age. The progression of the disease is usually slow, but can eventually lead to progressive joint dysfunction with pain and disability. OA of the hips and knees tends to cause the greatest changes, as pain and stiffness in these large, weight-bearing joints often lead to significant disability requiring surgery.
Pain as a distinct entity and a leading cause of disability
Pain is one of the most significant symptoms of many rheumatic diseases and is a dominant symptom in patients with inflammatory arthritis, as well as in patients with osteoarthritis. Pain is also a major factor in frequent doctor visits, sick leave, and disability, and thus has a substantial socioeconomic burden. Pain additionally affects the quality of sleep, and thus cognitive abilities and mood, and is often accompanied by malaise, fatigue, anxiety or depression. Therefore, pain in rheumatic diseases is recognized as a distinct clinical entity that requires dedicated attention during treatment.
Studies show that most patients with inflammatory arthritis report pain as the main burden of their disease, and pain relief is considered the the highest treatment priority. Chronic pain in IA can be present even in patients who have achieved adequate control of the underlying disease.
Advanced osteoarthritis (OA) of the hip, knee, hand, and spine is one of the most common causes of chronic pain that prevents patients from working, engaging in social activities, exercising, and maintaining an independent lifestyle. A full understanding of these conditions is needed, and in recent years, healthcare systems in all countries have allocated enormous costs to the diagnosis, treatment, sick leave, rehabilitation, and early retirement of patients with OA.
From all of the above, it is clear that pain management should be a priority in rheumatic disease treatment protocols and should be guided by scientific evidence and a detailed assessment of the patient’s individual condition, needs, preferences and priorities, pain characteristics, previous and current pain treatments, the degree of inflammation and/or joint damage, as well as physiological, psychological and other factors associated with pain. Pain management options typically include education, physical activity, exercise programs, use of assistive devices, psychological and social interventions, improvement of sleep patterns, weight management and, of course, pharmacological treatment.
ROLE OF PARACETAMOL IN THE TREATMENT OF PAIN IN RHEUMATIC DISEASES
Paracetamol is an analgesic and antipyretic medicine that is widely used as an effective and safe medicine that can be used in infants, the elderly, pregnant women and nursing mothers. Numerous studies have demonstrated the efficacy and safety of paracetamol in the treatment of mild to moderate pain, and it is included in the WHO Model list of essential medicines.
Clinicians often prefer to prescribe it due to better tolerance and safety, especially for patients in whom NSAIDs are contraindicated (e.g. peptic ulcer conditions, NSAID-sensitive asthma , cardiovascular diseases).
The progressive aging of the population is frequently associated with painful conditions, most commonly resulting from osteoarticular problems, with functional limitations, and disability that significantly affects quality of life. This should not be overlooked when selecting an analgesic for pain management in older patients with multiple comorbidities. Paracetamol reduces pain through several mechanisms of action, both as monotherapy and in synergy with other medicines, including NSAIDs and opioids. Owing to its efficacy, safety profile and low potential for drug interactions, paracetamol may represent the first-line treatment for painful conditions in older patients, as emphasised in numerous recommendations and clinical guidelines for the management of these conditions. Furthermore, the presence of multiple comorbidities is often accompanied by polypharmacy, which increases the risk of adverse drug reactions.
Lee YC. Effect and treatment of chronic pain in inflammatory arthritis Curr Rheumatol Rep. 2013; 15:300
https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02
Pain: the use of paracetamol in multimorbid patients, Francesco Salamone, Published online: November 14th, 2022