What are the recommended treatments for pain control in rheumatoid arthritis?

Pain Management in Rheumatoid Arthritis

Disease-modifying antirheumatic drugs (DMARDs) should be the foundation of pain control in rheumatoid arthritis, with methotrexate as the anchor drug, supplemented by NSAIDs, glucocorticoids, and non-pharmacological approaches as needed. 1

First-Line Treatment: DMARDs

DMARDs are essential for controlling the underlying inflammation that causes pain in RA:

• Methotrexate should be started as early as possible (ideally within 3 months of symptom onset) as the anchor DMARD 1, 2
• If methotrexate alone is insufficient, rapidly escalate to combination DMARDs or biologics 2
• For patients with inadequate response to conventional DMARDs, biologic agents (particularly TNF inhibitors like adalimumab) should be considered 3
• Adalimumab dosing for RA: 40 mg subcutaneously every other week 4

Clinical Pearl: Early aggressive DMARD therapy significantly reduces inflammatory pain by targeting the root cause rather than just masking symptoms 1

Adjunctive Pharmacological Approaches

NSAIDs

• Should be considered after evaluating gastrointestinal, renal, and cardiovascular risk factors 1
• Use at minimum effective dose for shortest time possible 1
• Options include:
  • Ibuprofen: Effective for pain control with potentially fewer GI side effects than aspirin 5
  • Naproxen: Comparable efficacy to aspirin with potentially better tolerability 6
  • COX-2 inhibitors: May have fewer GI side effects 1

Glucocorticoids

• Highly effective for rapid pain and inflammation reduction 1
• Administration options:
  • Systemic (oral, IV): For widespread symptoms
  • Intra-articular injections: For localized joint pain and swelling
• Should be used temporarily as bridging therapy while waiting for DMARDs to take effect 1
• Keep dosage to minimum for prolonged treatment due to side effect risk 1

Warning: Avoid focusing solely on pain management with NSAIDs or glucocorticoids without addressing underlying inflammation through DMARDs 1

Non-Pharmacological Approaches

These approaches should complement pharmacological treatment:

• Physical activity and exercise: Most consistently beneficial for pain management 1

  • Aerobic exercise
  • Strength and resistance training
  • Aquatic exercise
  • Mind-body exercise (yoga, tai chi)

• Psychological interventions: Cognitive behavioral therapy, mindfulness 1

• Occupational therapy: For joint protection and energy conservation 1

• Weight management: For overweight patients to reduce joint stress 1

Treatment Algorithm

1. Start with methotrexate as the anchor DMARD (with folic acid supplementation)
2. Add short-term glucocorticoids for rapid symptom control while waiting for DMARDs to take effect
3. Incorporate NSAIDs as needed based on risk assessment
4. Escalate to combination DMARDs or biologics if inadequate response to methotrexate alone
5. Implement non-pharmacological approaches throughout treatment

Monitoring and Assessment

• Regularly assess disease activity and pain characteristics 1
• Differentiate between inflammatory and non-inflammatory pain sources to guide treatment 1
• Use validated disease activity measures to track progress 1
• Monitor for medication side effects, particularly with long-term NSAID or glucocorticoid use 1

Important Caveat: Pain may persist despite well-controlled inflammation due to central sensitization, which may require different management approaches 1, 7