Хроническая боль и депрессия у больных ревматоидным артритом: результаты пятилетнего наблюдения
Хроническая боль и депрессия у больных ревматоидным артритом: результаты пятилетнего наблюдения
Лисицына Т.А., Абрамкин А.А., Вельтищев Д.Ю. и др. Хроническая боль и депрессия у больных ревматоидным артритом: результаты пятилетнего наблюдения. Терапевтический архив. 2019; 91 (5): 8–18. DOI: 10.26442/00403660.2019.05.000207
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Lisitsyna T.A., Abramkin A.A., Veltishchev D.Yu., et al. Chronic pain and depression in patients with rheumatoid arthritis: results of five-year follow-up. Therapeutic Archive. 2019; 91 (5): 8–18. DOI: 10.26442/00403660.2019.05.000207
Хроническая боль и депрессия у больных ревматоидным артритом: результаты пятилетнего наблюдения
Лисицына Т.А., Абрамкин А.А., Вельтищев Д.Ю. и др. Хроническая боль и депрессия у больных ревматоидным артритом: результаты пятилетнего наблюдения. Терапевтический архив. 2019; 91 (5): 8–18. DOI: 10.26442/00403660.2019.05.000207
________________________________________________
Lisitsyna T.A., Abramkin A.A., Veltishchev D.Yu., et al. Chronic pain and depression in patients with rheumatoid arthritis: results of five-year follow-up. Therapeutic Archive. 2019; 91 (5): 8–18. DOI: 10.26442/00403660.2019.05.000207
Цель исследования – анализ факторов, влияющих на хроническую боль у пациентов с ревматоидным артритом (РА). Материалы и методы. Обследовано 128 пациентов с достоверным диагнозом РА [111 (86,7%) женщин и 17 (13,3%) мужчин]. Средний возраст больных составил 47,4±11,3 года, медиана длительности заболевания – 96 [48; 228] мес. При включении в исследование у большинства пациентов активность РА по DAS28 была умеренной (n=56; 43,7%) или высокой (n=48; 37,5%). Для определения выраженности боли и ее влияния на различные аспекты жизни использовали шкалу BPI (Brief Pain Inventory). Расстройства тревожно-депрессивного спектра (РТДС) диагностированы психиатром в ходе полуструктурированного интервью по критериям МКБ-10 у 123 (96,1%) пациентов. Выраженность депрессии определяли по шкале депрессии Монтгомери–Асберг, тревоги – по шкале тревоги Гамильтона. Для диагностики когнитивных нарушений использовали клинико-психологические методики. Психофармакотерапия (ПФТ) предложена всем пациентам с РТДС, из них согласились на лечение 52, отказался – 71 пациент. В зависимости от проводимой терапии выделены следующие терапевтические группы: 1-я – базисные противовоспалительные препараты (БПВП; n=39), 2-я – БПВП+ПФТ (n=43), 3-я – БПВП+генно-инженерные биологические препараты (ГИБП; n=32), 4-я – БПВП+ГИБП+ПФТ (n=9). Динамику РТДС и исходы РА через 5 лет оценивали у 83 (67,5%) больных. Результаты. При включении в исследование 94 (75,2%) пациента с РА испытывали умеренную и сильную боль. По данным регрессионного анализа, максимальная выраженность боли по BPImax через 5 лет наблюдения ассоциировалась не только с факторами, характеризующими РА – высокой активностью по DAS28, уровнем высокочувствительного С-реактивного белка, выраженностью суставной деструкции, степенью функциональных ограничений, длительностью РА и меньшей длительностью приема глюкокортикоидов, но также с сохраняющимися депрессивными эпизодами в рамках рекуррентной депрессии и исходным наличием когнитивных нарушений. Выраженность боли через 5 лет наблюдения была выше при лечении РА только базисными препаратами, без применения ГИБП и в отсутствии ПФТ сопутствующих РТДС. Заключение. Депрессивный эпизод в рамках рекуррентной депрессии является значимым фактором хронизации боли у больных РА. Своевременная эффективная ПФТ депрессии, подобранная с учетом ее структуры и личностных особенностей пациента, приводит к стойкому уменьшению выраженности боли у больных РА.
The aim of the study was to analyze the factors affecting chronic pain in pa-tients with rheumatoid arthritis (RA). Materials and methods. 128 patients with reliable diagnosis of RA [111 (86.7%) women and 17 (13.3%) men] were examined. The mean age of patients was 47.4±11.3 years, the median duration of the disease was 96 [48; 228] months. When included in the study in most patients, the activity of RA in DAS28 was moderate (n=56; 43.7%) or high (n=48; 37.5%). BPI (Brief Pain Inventory) scale was used to determine the severity of pain and its impact on various aspects of life. The anxiety-depressive spectrum disor-ders (ADDs) were diagnosed by psychiatrist during a semi-structured inter-view according to ICD-10 criteria in 123 (96.1%) patients. The severity of depression was determined by the Montgomery–Asberg depression rating scale, anxiety – by Hamilton anxiety scale. For the diagnosis of cognitive impairment used clinical and psychological techniques. Psychopharma-cotherapy (PPhT) by antidepressants or anxiolytics is offered to all patients with ADDs, 52 of them agreed to treatment, 71 patients refused. The next groups selected depending on the therapy: 1st – with conventional disease-modifying antirheumatic drugs (cDMARDs; n=39), 2nd – with cDMARDs+PPhT (n=43), 3d – with cDMARDs + biologic (b) DMARDs (n=32), 4th – with cDMARD+bDMARDs+PPhT (n=9). The dynamics of ADDs and outcomes of RA in 5 years were evaluated in 83 (67.5%) patients. Results. When included in the study, 94 (75.2%) patients with RA had moderate and severe pain. According to the regression analysis, the maximum intensity pain in BPImax after 5 years of follow-up associated not the only factors connected with RA – high DAS28, the serum level of C-reactive protein, the degree of radiological stage and functional insufficiency, duration of RA and a lesser duration of glucocorticoids intake, but also with continuing depressive episodes in the framework of recurrent depression and the initial presence of cognitive impairment. The severity of pain after 5 years of follow-up was higher in RA patients receiving only сDMARDs, without the use of bDMARDs and in the absence of PPhT associated with ADDs. Conclusion. Depressive episode within recurrent major depression is a significant factor in the chronicity of pain in patients with RA. Timely effective PPhT of depression, selected taking into account depression structure and personal characteristics of the patient, leads to a steady decrease in the severity of pain in patients with RA.
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1. Mifflin KA, Ker BJ. Pain in Autoimmune Disorders. J Neurosci Res. 2017 Jun;95(6):1282-94. doi: 10.1002/jnr.23844
2. Ryan S, McGuire B. Psychological predictors of pain severity, pain interference, depression, and anxiety in rheumatoid arthritis patients with chronic pain. Br J Health Psychol. 2016May;21(2):336-50. doi: 10.1111/bjhp.12171
3. Smith HS, Smith AR, Seidner P. Painful Rheumatoid Arthritis. Pain Physician. 2011;14:E427-E458.
4. Borenstein D, Altman R, Bello A, et al. Report of the American College of Rheumatology Pain Management Task Force. Arthritis Care Res (Hoboken). 2010;62(5):590-9. doi: 10.1002/acr.20005
5. Studenic P, Radner H, Smolen JS, Aletaha D. Discrepancies between patients and physicians in the perception of rheumatoid arthritis disease activity. Arthritis Rheum. 2012;64:2814-23. doi: 10.1002/art.34543
6. Courvoisier N, Dougados M, Cantagrel A, et al. Prognostic factors of 10-year radiographic outcome in early rheumatoid arthritis: a prospective study. Arthritis Res Ther. 2008;10(5):R106. doi: 10.1186/ar2498
7. Lee YC, Cui J, Lu B, Frits ML, Iannaccone CK, Shadick NA, Weinblatt ME, Solomon DH. Pain persists in DAS28 rheumatoid arthritis remission but not in ACR/ EULAR remission: a longitudinal observational study. Arthritis Res Ther. 2011;13(3):R83. doi: 10.1186/ar3353
8. Koop SM, ten Klooster PM, Vonkeman HE, et al. Neuropathic-like pain features and cross-sectional associations in rheumatoid arthritis. Arthritis Res Ther. 2015;17:237. doi: 10.1186/s13075-015- 0761-8
9. McWilliams DF, Zhang W, Mansell JS, et al. Predictors of change in bodily pain in early rheumatoid arthritis: an inception cohort study. Arthritis Care Res (Hoboken). 2012;64(10):1505-13. doi: 10.1002/acr.21723
10. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Comorbidity: A Literature Review. Arch Intern Med. 2003;163(20):2433-45. doi: 10.1001/archinte.163.20.2433
11. Vietri J, Otsubo T, Montgomery W, Tsuji T, Harada E. Association between pain severity, depression severity, and use of health care services in Japan: results of a nationwide survey. Neuropsychiatric Disease and Treatment. 2015;11:675-83. doi: 10.2147/NDT.S71768
12. Nicol AL, Sieberg CB, Clauw DJ, Hassett AL, Moser SE, Brummett CM. The association between a history of lifetime traumatic events and pain severity, physical function, and affective distress in patients with chronic pain. J Pain. 2016;17(12):1334-48. doi: 10.1016/j.jpain.2016.09.003
13. Dougados M, Soubrier M, Antunez A, Balint P, Balsa A, Buch MH, Kay J. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring results of an international, cross-sectional study (COMORA). Annals of the Rheumatic Diseases. 2014;73(1):62-8. https://doi.org/10. 1136/annrheumdis-2013-204223
14. Matcham F, Rayner L, Steer S, Hotopf M. The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2013;52:2136-48. https://doi.org/10.1093/rheumatology/ ket169
15. Abramkin AA, Lisitsyna TA, Veltishchev DY, Seravina OF, Kovalevskaya OB, Glukhova SI, Nasonov EL. Factors influencing the efficiency of therapy in patients with rheumatoid arthritis: the role of comorbid mental and somatic diseases. Rheumatology Science and Practice. 2018;56(4):439-48 (In Russ.). https://doi.org/10.14412/1995-4484-2018-439-448
16. Zautra AJ, Parrish BP, Van Puymbroeck ChM, Tennen H, Davis MC, Reich JW, Irwin M. Depression History, Stress, and Pain in Rheumatoid Arthritis Patients. J Behav Med. 2007;30:187-97. doi: 10.1007/s10865-007-9097-4
17. Lisitsyna TA, Vel'tishchev DIu, Gerasimov AN, Seravina OF, Kovalevskaia OB, Zel'tyn' AE, Novikov AA, Aleksandrova EN, Tallerova AV, Kovalenko LP, Durnev AD, Krasnov VN, Nasonov EL. Perception of pain in rheumatoid arthritis: relation to inflammation, psychic disorders, functional status, and quality of life. Klin Med (Moscow). 2013;91(3):54-61 (In Russ.).
18. Jobski K, Luque Ramos A, Albrecht K, Hoffmann F. Pain, depressive symptoms and medication in German patients with rheumatoid arthritis—results from the linking patient-reported outcomes with claims data for health services research in rheumatology (PROCLAIR) study. Pharmacoepidemiol Drug Saf. 2017 Jul;26(7):766-74. doi: 10.1002/pds. 4202
19. Ødegard S, Finset A, Mowinckel P, Kvien TK, Uhlig T. Pain and psychological health status over a 10-year period in patients with recent onset rheumatoid arthritis. Ann Rheum Dis. 2007;66:1195-201. doi: 10.1136/ard.2006.064287
20. Challa DN, Kvrgic Z, Cheville AL, Crowson CS, Bongartz T, Mason TG 2nd, Matteson EL, Michet CJ Jr, Persellin ST, Schaffer DE, Muskardin TLW, Wright K, Davis JM 3rd. Patient-provider discordance between global assessments of disease activity in rheumatoid arthritis: a comprehensive clinical evaluation. Arthritis Research & Therapy. 2017; 19:212. doi: 10.1186/s13075-017-1419-5
21. Aletaha D, et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-81. doi: 10.1002/art.27584
22. Revmatologiya. Rossiiskie klinicheskie rekomendatsii. Pod red. EL. Nasonova. Moscow: GEOTAR-Media, 2017. 464 s. (In Russ.).
23. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory [review]. Ann Acad Med Singapore. 1994;23:129-38.
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1 ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой», Москва, Россия;
2 Московский научно-исследовательский институт психиатрии – филиал ФГБУ «Национальный медицинский исследовательский центр психиатрии и наркологии им. В.П. Сербского» Минздрава России, Москва, Россия;
3 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России, (Сеченовский Университет), кафедра ревматологии Института профессионального образования, Москва, Россия;
4 ФГБОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, кафедра психиатрии факультета дополнительного профессионального образования (ФДПО), Москва, Россия
1 V.A. Nasonova Scientific and Research Institute of Rheumatology, Moscow, Russia;
2 Moscow Research Institute of Psychiatry – Branch National Medical Research Center of Psychiatry and Narcology, Ministry of Health of Russia, Moscow, Russia;
3 I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Department of Rheumatology, Institute of Professional Education, Moscow, Russia;
4 Pirogov Russian National Research Medical University, Ministry of Health of Russia, department of psychiatry, Moscow, Russia