Pain in inflammatory arthritis – evidence-based recommendations

 

RA

Palanisamy Vijayanand

Inflammatory arthritis (IA) – rheumatoid arthritis (RA), psoriatic arthritis, ankylosing spondylitis and spondyloarthritis – affects up to 3% of the population. In addition to stiffness, loss of function and impaired quality of life, pain is an important predicament. Currently, there is limited data to inform clinical practice in managing pain. Moreover, as very little evidence stands on its own, incorporating research results into clinical practice requires discernment. The 3e (Evidence, Expertise, Exchange) Initiative is a multinational collaboration that promotes evidence-based practice in rheumatology. Using sound methods, a recent research generates recommendations that are designed to be relevant to everyday clinical practice, and aid the clinician in the difficult task of balancing individual patient need for effective pain control with the medication-specific risks. The clinically relevant questions, recommendations and level of evidence are as follows:

1. How do we measure/score pain and how do we monitor effectiveness of pain treatment in inflammatory arthritis?

Recommendation: Pain is assessed routinely in the context of the global physician evaluation. If formal measurement of pain is required then a visual analogue scale (VAS), verbal rating scale (VRS) or numerical rating scale (NRS) can be used and each are feasible to apply in clinical practice.

Level of Evidence: N/A. Grade of recommendation: N/A

 

2. What is the effectiveness, safety and role of paracetamol (acetaminophen) in pain management in patients with inflammatory arthritis (i.e., interval, formulation and route)?

Recommendation: Paracetamol is a useful adjunct alone or in combination with NSAIDs in pain management in IA.

RA: Level of Evidence: 2b. Grade of recommendation: C

Other IA: Level of Evidence 5. Grade of recommendation: D

 

3. What are the effectiveness, safety and role of corticosteroids for pain relief in persistent pain of inflammatory arthritis (i.e., interval, formulation and route)?

Recommendation: There is no role for glucocorticoids as analgesics in the absence of inflammation in patients with IA.

Level of Evidence: 5. Grade of recommendation: D

 

4. What are the effectiveness, safety and role of antidepressants, neuromodulators and muscle relaxants in pain management in patients with inflammatory arthritis (i.e., interval, formulation and route)?

Recommendations:

a) There is a role for tricyclic antidepressants for pain management in some patients with IA

Level of Evidence: 5. Grade of recommendation: D

b) There is no role for muscle relaxants in the treatment of pain associated with IA

Level of Evidence: 5 Grade of recommendation: D

c) There may be a role for oral neuromodulators but current evidence is lacking.

RA: Level of Evidence: 2b. Grade of recommendation: C

Other IA: Level of Evidence: 5. Grade of recommendation: D

 

5. What are the effectiveness, safety and role of opioids or opioid-like therapy in inflammatory arthritis and how should it be administered (i.e., interval, formulation and route)?

Recommendation: Opioids can be useful in some patients with persistent pain despite optimal control of inflammatory activity.

RA: Level of Evidence: 2b. Grade of recommendation: D

Other IA: Level of Evidence: 5. Grade of recommendation: D

 

6. Is there a difference in efficacy and safety between on demand and continuous use of NSAIDs in inflammatory arthritis?

Recommendation: NSAIDs can be used continuously or on demand according to clinical circumstances.

Level of Evidence: 5 Grade of recommendation: D

 

7. How do co-morbidities influence the choice of pain treatment in inflammatory arthritis?

a) GI and liver

b) CV and kidney

Recommendations:

a) NSAIDs are associated with an increased risk of GI events in patients with IA who have had a prior GI event.

b) If NSAIDs are considered in patients with IA and high GI risk, concurrent treatment with a PPI is recommended.

c) COX-2 selective NSAIDs have less risk of GI adverse events than non-selective NSAIDs and should be preferentially considered in patients with IA and high GI risk.

RA: Level of Evidence: 3. Grade of recommendation: C

Other IA: Level of Evidence: 5. Grade of recommendation: D

 

8. Is it safe to use NSAIDs and/or paracetamol with methotrexate in the management of patients with inflammatory arthritis?

Recommendations:

a)  In patients with renal impairment, NSAIDs should be used with caution.

b) In patients with hypertension NSAIDs can be used with blood pressure monitoring.

c) In patients with established cardiovascular disease or risk factors for cardiovascular disease, caution should be exercised when prescribing NSAIDs.

RA: Level of evidence: 2a. Grade of recommendation: C

Other IA: Level of Evidence: 5. Grade of recommendation: D

 

9. What pain therapy can be used safely in the preconception, pregnancy and lactation periods in inflammatory arthritis?

Recommendation: Methotrexate toxicity is not increased by concurrent use of NSAIDs (excluding anti-inflammatory doses of aspirin) and/or paracetamol.

RA and NSAIDs: level of evidence: 4. Grade of recommendation: C

Other IA and NSAIDs: level of evidence: 5. Grade of recommendation: D

All IA and paracetamol: level of evidence: 5. Grade of recommendation: D

 

10. What is the optimal treatment strategy (algorithm) for management of pain in inflammatory arthritis (monotherapy, stepwise, combination)?

Recommendation: In the absence of sufficient evidence, pain therapy in pregnancy and lactation should follow current local guidelines.

Level of Evidence: 5. Grade of recommendation: D

The data that was available was of low quality and predominantly only included patients with RA in the pre-biologic era receiving treatments not reflective of current-day practice. There was also no data on many analgesics in common use today. This was reflected in the low Oxford levels of evidence for each of the recommendations. These recommendations, like a pointillist image, are a coalescence of scattered information. Importantly, it is a guide to managing the pain of inflammatory arthritis, especially on whether to reach for the hammer or the screwdriver.

Summary
Article Name
Pain in inflammatory arthritis – evidence-based recommendations
Author
Description
Evidence-based recommendations for managing pain of inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and spondyloarthritis)
Dr. Palanisamy Vijayanand

Post author

FCARCSI, DPainMed (RCSI), MSc (Pain), FFPMCAI, FFPMANZCA | Hyderabad, India

There are 1 Comment

  1. Posted by madhur Reply

    Nice one sir.

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