Philip Mease, MD: The Complexities of Treating Pain in Rheumatic Disease

In an interview with HCPLive, Philip Mease, MD, clinical professor at the University of Washington School of Medicine and Director of Rheumatology Research at the Swedish Medical Center in Seattle, discussed his Rheumatology Winter Clinical Symposium (RWCS) presentation, “State of the Art: Pain (simple title, complex issue).”

Mease was asked to present his findings in part due to his interest in the experience of pain that patients exhibit, which is in parallel with his research, clinical, and educational concentration in inflammatory arthritis conditions, such as psoriatic arthritis, rheumatoid arthritis, lupus, and axial spondyloarthritis. He noted that over the last few decades, there has been an increasing awareness of the different pathophysiological causes of pain.

“It turns out that when a person has a chronic painful condition or an autoimmune condition with inflammation, changes occur in both the peripheral and central nervous system,” Mease stated. “Depending upon your genetic makeup and/or gender and other psychosocial stressors in your life, you have an upregulation of gene expression for what we call nociceptive neuropeptides.”

Fibromyalgia, which is more commonly diagnosed in female patients, is a more complex entity that includes not only nociplastic pain, but also symptoms such as fatigue, abdominal pain, sleep disturbance, and irritable bowel syndrome, among others, which increase central sensitization.

“In part, that has to do with genetics of females; they're just more aware,” Mease hypothesized. “Sometimes women feel slighted by the fact that they have a greater likelihood of fibromyalgia or central sensitization. But on the other hand, there's an adaptive value to it.”

Mease wondered how much of a patient’s pain experience is due to their primary rheumatic disease and how much is due to the central sensitization phenomenon.

“If a person comes in and says, ‘I'm in a lot of pain, I'm fatigued, I'm not sleeping well, and I don't think my drug is working well enough for me’ but then they have a completely normal C-reactive protein, no swollen joints, and their skin is completely clear, it's valuable,” Mease underscored. “It's worthwhile for us to [consider] that there are other factors going on besides an uptick of their underlying psoriatic arthritis. Maybe we need to think about other approaches to managing their residual pain and fatigue. That's why it's important both in clinical trials and clinical practice to be aware of these different streams of the pain experience.”