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Fabry disease is a multisystemic life-threatening lysosomal storage disorder caused by deficiency of α-galactosidase A. Symptoms of the disease may occur in different organs including kidney, heart, and the nervous system.To evaluate the nature and prevalence of pain in a large cohort of patients with Fabry disease and to assess the effect of enzyme replacement therapy (ERT) with agalsidase alfa.Retrospective analysis of the data of 752 patients with Fabry disease (393 females, 353 males) enrolled in the Fabry Outcome Survey, a multicentre database.The prevalence of pain in male patients was 81.4% (females 65.3%). Mean age at onset of pain was 14.8±1.0 year in males (females 19.8±1.4 y). Pain was most frequently reported in the hands (males 76%, females 60%) and feet (males 73%, females 52%), but often affected the whole body. Interference of pain with daily life was higher in females than in males, and was observed predominantly for general activities, mood, and normal work. Fifty-eight percent of the patients were on ERT with agalsidase alfa. At 24 and 36 months after commencement of ERT, pain severity classification shifted towards lower severity (P<0.05). Moreover, after 36 months, “average pain” and “pain now” were significantly reduced (P<0.05).Pain is one of the most prevalent symptoms in Fabry disease with onset early in childhood. ERT with agalsidase alfa significantly reduces pain in this debilitating disorder.