The rheumatology month in review addresses concerns regarding opioid use in rheumatic diseases while emphasizing the importance of holistic approaches to healthcare, incorporating lifestyle modifications, evidence-based guidelines, and personalized treatment plans to improve patient outcomes in chronic conditions.

Presence, Reliance on Opioids

Few health crises have garnered as much attention from both public health professionals and the United States (US) general public as the opioid epidemic. However, opioids are not usually recommended to treat rheumatic diseases. Rather, the US treatment guidelines recommend conventional synthetic and biologic disease-modifying antirheumatic drugs (csDMARDS/bDMARDs) to relieve pain.

Opioid use among patients with rheumatic disease has been linked to worse patient-reported outcomes, increased prevalence of depression, reduced efficacy of csDMARDs, and greater safety concerns.

Opioid Prescriptions Nearly 3 Times More Likely in Patients with Rheumatic, Autoimmune Diseases

Results of an analysis of data from the National Ambulatory Medical Care Survey indicate patients with systemic autoimmune or inflammatory rheumatic diseases were nearly 3 times as likely to receive a prescription for opioids as their counterparts without such conditions during the study period.

“In light of limited data about the efficacy of chronic opioid use in systemic autoimmune rheumatic diseases (SARDs) and potential adverse effects, the current data warrant vigilance from rheumatologists in prescribing opioids for SARDs patients,” wrote a team of investigators led by Yinan Huang, MS, PhD, of the Department of Pharmacy Administration at the School of Pharmacy at University of Mississippi. “Non-opioid alternatives for pain management should also be considered. There is also a need to optimize the use of the disease-modifying antirheumatic drugs.”

Patients with new AS, PSA, RA Diagnosis Have High Reliance on Opioids

Investigators conducted a retrospective cohort study aiming to describe patients’ opioid usage in the year before and following a new diagnosis of ankylosing spondylitis (AS), psoriatic arthritis (PsA), and rheumatoid arthritis (RA), compared to controls. Each patient was matched with 3 comparators who did not have incident disease based on birth year, sex, calendar year of index, region, and insurance plan type.

Overall, patients with an incident disease had a greater prevalence of opioid claims opioids than the comparators. Prevalence ratios for chronic opioid use in the follow-up were greater for patients with AS (3.82; 95% confidence interval [CI], 3.51 – 4.15), PsA (2.41; 95% CI, 2.25 – 2.58), and RA (3.22; 95% CI, 3.15 – 3.28), compared to comparators.

The prevalence ratios for long-term opioid use in the follow-up were also greater for AS (3.51; 95% CI, 3.25 – 3.79), PsA (2.25; 95% CI, 2.11 – 2.40), and RA (2.99; 95% CI, 2.94 – 3.05) than comparators.

“These findings suggest that patients are still experiencing pain, and the peak in opioid use leading up to diagnosis suggests that this pain may be due to these diseases,” wrote investigators, led by Anna Sheahan, PhD, of UCB Pharma.

Benefits of Exercise, Diet for Managing Fibromyalgia

This month’s articles included studies that explored the significant impact of lifestyle modifications, particularly physical fitness and diet, on the management and improvement of symptoms in women with fibromyalgia.

Physical Fitness Linked to All Gait Parameters for Women with Fibromyalgia

Assessing gait parameters can help monitor patients' general health and functional status to ensure they receive timely interventions. However, patients with fibromyalgia are often afraid of exerting themselves with physical activity. This promotes greater sedentary behaviors for patients with fibromyalgia and comparable physical fitness levels to those of elderly populations.

Investigators conducted a cross-sectional study to assess the individual and independent associations of moderate-to-vigorous physical activity, sedentary time, fat percentage, and physical fitness with gait parameters in 84 women with fibromyalgia.

Results demonstrated maintaining good levels of moderate-to-vigorous physical activity, physical fitness, and appropriate weight balance is associated with improvements in gait parameters among this population.

Mediterranean Diet Improves Pain, QoL in Patients with Fibromyalgia

Outpatients with fibromyalgia were enrolled in a study, which included clinical, nutritional, and dietary assessments, to evaluate the effect of a Mediterranean diet on fibromyalgia symptoms.

Patients were randomized 1:1 and placed into either the personalized Mediterranean diet cohort (DIET) or the balanced diet based on the individual’s body mass index cohort (NODIET). They were evaluated at baseline, week 4, and again at week 8.

Those who followed the personalized Mediterranean diet protocol reported improvements in both pain and quality of life.

Highlights From CCR East

A common theme of this year’s 2024 Congress of Clinical Rheumatology (CCR) East coverage revolved around the inherent complexity and the need for more standardized and evidence-based approaches in clinical practice guidelines for chronic conditions such as chronic pain, RA, and osteoporosis. Insight from rheumatologists collectively underscore the necessity for clear, consistent, and patient-centered guidelines to enhance treatment outcomes and navigate the complexities of managing chronic diseases.

Untangling Clinical Practice Guidelines for Chronic Pain, with Jason Busse, DC, PhD

In an interview with HCPLive, Jason Busse, DC, PhD, professor in the Departments of Anesthesia and Health Research Methods, Evidence and Impact at McMaster University, described the discrepancies and contradictions across guidelines regarding the management of chronic pain.

Busse pointed to a recent review of clinical practice guidelines for interventional procedures in chronic spine pain management that revealed 21 guidelines with no consistency in recommendations. Similarly, guidelines for opioids vary widely, with Centers for Disease Control and Prevention (CDC) advocating for their use based on perceived benefits exceeding harms, while other organizations, such as the US Department of Defense and Veterans Affairs, strongly advise against them. This inconsistency creates a challenging landscape for practitioners and patients to navigate.

“It has been a real failing of the research community in terms of providing all of this chaos out there,” he said.

Navigating ACR’s RA Treatment Guidelines, with Bryant England, MD, PhD

Bryant England, MD, PhD, associate professor in the Division of Rheumatology at the University of Nebraska Medical Center, discussed the American College of Rheumatology (ACR)'s clinical practice guidelines—with an emphasis on the pharmacologic and integrative treatment guidelines—to help clinicians incorporate the latest recommendations into their clinical practice.

As a part of the core team for the pharmacologic guideline and the co-principal investigator for the integrative guideline, England emphasized they integrate the best available evidence, clinical experiences, and patient values and preferences. This evidence-based approach is particularly vital in chronic diseases like RA, where treatment decisions require continuous assessment and adaptation based on evolving evidence and patient circumstances.

Current Concepts in the Management of Osteoporosis, with E. Michael Lewiecki, MD

Despite advancements in fracture risk assessment and treatment strategies, E. Michael Lewiecki, MD, director of New Mexico Clinical Research & Osteoporosis Center, says the development of new osteoporosis drugs has slowed due to the cost and complexity of large clinical trials focused on fracture endpoints. Future prospects depend on potential changes in US Food and Drug Administration (FDA) guidelines for clinical trial designs, which might encourage the emergence of novel treatments. However, according to Lewiecki, no imminent breakthroughs are anticipated in the near future.

Ultimately, the management of osteoporosis underscores the importance of risk assessment, personalized treatment plans, and ongoing monitoring to mitigate fracture risk effectively and improve patient outcomes.