11 recommendations reported for arthritis pain management

A set of 11 evidence-based recommendations for managing pain with pharmacotherapy in patients suffering inflammatory arthritis (IA) were reported by an international panel online March 24 in Rheumatology.

The guidelines, reported by Samuel L. Whittle, Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, and colleagues, were developed by a group of 453 rheumatologists from 17 countries who participated in the 2010 3e (Evidence, Expertise, Exchange) Initiative.

The panel formulated and selected 10 clinically relevant questions regarding IA pain management via a modified Delphi voting process. A team of 10 multinational fellows conducted a systematic literature review for each question. One question was split into 2 parts in order to better manage the amount of related evidence, resulting in 11 recommendations and a treatment algorithm.

The panel’s findings:

Pain should be measured routinely with the visual analog scale, numerical rating scale, or verbal rating scale.

Paracetamol (acetaminophen) is recommended for the treatment of persistent pain.

Systemic glucocorticoids should be avoided for routine pain management when signs and symptoms of inflammation are absent.

Tricyclic antidepressants (TCAs) and neuromodulators are recommended for adjuvant use only, but muscle relaxants or benzodiazepines are not.

Weak opioids are recommended for short-term treatment of pain only when other treatments have failed or are contraindicated but caution should be advised for long-term use and strong opioids should only be used in extreme cases under close supervision.

A drug with a different mode of action should be added if acetaminophen or nonsteroidal anti-inflammatory drug (NSAID) monotherapy is inadequate, but 2 or more NSAIDs should not be combined.

The lowest effective NSAID dose should be used.

Existing guidelines for the safety of pain pharmacotherapies during preconception, pregnancy, and lactation should be followed.

Methotrexate can be used safely in combination with standard doses of paracetamol and/or NSAIDs (excluding anti-inflammatory doses of aspirin).

Paracetamol is recommended as first choice for pain relief in patients with gastrointestinal comorbidities, but non-selective NSAIDs in combination with proton-pump inhibitors (PPIs) or COX-2 selective inhibitors with or without PPIs should be used with caution.

Paracetamol is recommended as first choice for pain relief in patients with pre-existing hypertension, cardiovascular, or renal disease, and NSAIDs, including COX-2 selective inhibitors, should be used cautiously.

“The recommendations represent the integration of the best available evidence and multinational clinical expertise, and as such remain a valuable tool for rheumatologists in the clinic,” the authors noted.

“Moreover, our findings highlight the need for further well-designed clinical trials of analgesic drugs in patients with a variety of inflammatory arthropathies, taking into account current immunomodulatory strategies, novel analgesic drugs and modern understanding of the neurobiology of pain.”