Visualizing Real-World Pain Treatment Pathways in Chronic Disease: A Sequence-Based Analysis of Polypharmacy in Systemic Lupus Erythematosus

Objective: To examine real-world patterns in pain management among adults with systemic lupus erythematosus (SLE), we focused on the sequencing of pain modalities, polypharmacy, and demographic variation. Methods: We conducted a retrospective analysis of electronic health records from adults with SLE treated at a single academic medical center between 2005 and 2024. We included patients who received at least one pain-related therapy, including glucocorticoids, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, anticonvulsants, muscle relaxants, and nonpharmacologic interventions. We used sequence analysis and Sankey diagrams to map treatment trajectories and compared patterns across two periods: 2005 to 2014 and 2015 to 2024. Polypharmacy was defined as receiving five or more pain-related prescriptions within 12 months. We examined trends by age, sex, and race or ethnicity. Results: Among 769 patients, initiation of glucocorticoids and opioids declined over time (58%–51% and 28%–22%, respectively), whereas NSAID use increased (19%–29%). The median number of pain prescriptions decreased, and polypharmacy prevalence dropped from 53% to 45%. In recent years, younger adults and men received more prescriptions, with 69% of men receiving five or more compared with 43% of women. Racial disparities narrowed overall in recent years but persisted in sensitivity analyses excluding glucocorticoids. Conclusion: Pain management in SLE is shifting away from high-risk therapies; however, prescribing intensity remains high and varies by demographic group. Visualizations serve as a complementary lens to traditional prescription counts, allowing representation of polypharmacy not only by volume but also by the diversity and sequencing of therapeutic classes over time.

Duke Scholars

Author Martha Kenney Anesthesiology, Pediatrics