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Monday, 14 May 2012

New Evidence-Based Treatment Recommendations for Inflammatory Arthritis

Study Highlights

A total of 453 rheumatologists from 17 countries participated in the 2010 3e (Evidence, Expertise, Exchange)Initiative. Using a formal voting process, 89 rheumatologists selected 10 clinical questions regarding the use of pain medications in IA. Nonpharmacologic interventions were not considered.

  • IA was defined as comprising RA, psoriatic arthritis (PsA), ankylosing spondylitis (AS), and spondyloarthritis (SpA).
  • Bibliographic fellows undertook a systematic review of the literature for each question, using MEDLINE, EMBASE, Cochrane CENTRAL, and 2008-2009 European League Against Rheumatism/American College of Rheumatology abstracts.
  • Relevant studies were retrieved for data extraction and quality assessment.
  • Rheumatologists from each country used this evidence to develop a set of national recommendations.
  • Multinational recommendations were then formulated and assessed for agreement and the potential impact on clinical practice.
  • Results demonstrated that a total of 49,242 references were identified, from which 167 studies were included in the systematic reviews.
  • A clinical question regarding different comorbidities was divided into 2 separate reviews, resulting in following recommendations.

  • The following are the recommendations:  
    1. Pain should be measured routinely using one of the following validated scales: the visual analog scale, the numeric rating scale, or the verbal rating scale. In addition, multidimensional measures or site-specific tools should be considered as needed.
    2. Paracetamol is recommended for the treatment of persistent pain in patients with IA.
    3. Systemic glucocorticoids are not recommended for the routine management of pain in patients with IA in the absence of signs and symptoms of inflammation.
    4. TCAs and neuromodulators may be considered for uses as adjuvant treatment; muscle relaxants and benzodiazepines cannot be recommended.
    5. Weak opioids may be used for short-term treatment of pain in patients with IA when other therapies have failed or are contraindicated; long-term use may be considered and should be regularly reviewed. Strong opioids should only be used in exceptional cases.
    6. In patients with an inadequate response to paracetamol or NSAID monotherapy, adding a drug with a different mode of action could be considered; combination of 2 or more NSAIDs should not be used.
    7. NSAIDs should be used at the lowest effective dose, either continuously or on demand, according to clinical circumstances.
    8. Existing guidance regarding the safety of pain pharmacotherapies during preconception, pregnancy, and lactation should be applied.
    9. Methotrexate can be safely used in combination with standard doses of paracetamol and/or NSAIDs.
    10. In patients with gastrointestinal comorbidities, paracetamol should be considered first; nonselective NSAIDs in combination with PPIs, or COX-2 selective inhibitors plus a PPI, may be used with caution. In the presence of liver disease, standard precautions for use of NSAIDs and other analgesics should be applied.
    11. In patients with IA and preexisting hypertension, cardiovascular disease, or renal disease, paracetamol should be used first; NSAIDs including COX-2 selective inhibitors should be used with caution.
    An algorithm for the pharmacologic management of pain in IA was developed. The first goal is to optimally control inflammation with disease-modifying antirheumatic drugs according to current practice.

    20% of rheumatologists reported that the algorithm would change their practice, and 75% believed that the algorithm was in accordance with their current practice.

    The recommendations were published online March 24 in Rheumatology.