What is a suitable nighttime pain reliever for a 62-year-old male patient with psoriatic arthritis, currently on sulfasalazine (Azulfidine) and Prednisone, who experiences inadequate pain relief from acetaminophen (Tylenol) for hip and leg pain?

Nighttime Pain Management for Psoriatic Arthritis

For a 62-year-old male with psoriatic arthritis experiencing inadequate nighttime pain relief from acetaminophen, an NSAID such as celecoxib (100-200 mg) at bedtime is recommended as the most appropriate stronger pain reliever option. 1, 2

Assessment of Current Treatment

The patient is currently on:

• Sulfasalazine 3 grams/day
• Prednisone 4 mg daily
• Acetaminophen (Tylenol) for supplemental pain relief

Despite this regimen, the patient reports inadequate nighttime pain control in the hips and legs, which is affecting sleep quality.

Recommended Treatment Approach

First-line Option: NSAIDs

• Celecoxib 100-200 mg at bedtime is recommended as the most appropriate option 1, 2
  • Provides stronger pain relief than acetaminophen
  • Has demonstrated efficacy in psoriatic arthritis
  • The evening dose can specifically target nighttime pain
  • May have better GI tolerability than traditional NSAIDs

Rationale for NSAID Selection

1. The American College of Rheumatology guidelines recommend NSAIDs as first-line therapy for pain management in spondyloarthritis, including psoriatic arthritis 1
2. NSAIDs have shown efficacy for musculoskeletal symptoms in psoriatic arthritis 1
3. The PRECISION trial demonstrated celecoxib's cardiovascular safety profile at appropriate doses 2
4. The patient's current regimen with sulfasalazine is appropriate for disease modification, but inadequate for pain control 1

Important Considerations

Monitoring and Precautions

• Cardiovascular risk: Monitor blood pressure regularly, especially in a 62-year-old male 2
• Renal function: Assess baseline kidney function before starting NSAIDs 2
• GI protection: Consider adding a proton pump inhibitor if GI risk factors are present 2
• Drug interactions: Check for potential interactions with current medications

Alternative Options (if NSAIDs are contraindicated)

1. Topical agents:

   • Topical diclofenac or capsaicin may provide localized relief with fewer systemic effects 1
   • However, these may be less effective for deep hip pain

2. Low-dose tricyclic antidepressants:

   • Amitriptyline 10-25 mg at bedtime can help with pain and sleep disturbance
   • May be particularly helpful if pain has a neuropathic component

Disease Management Considerations

If nighttime pain persists despite optimized pain management, consider:

1. Evaluating disease activity: Persistent pain may indicate inadequate disease control requiring adjustment of disease-modifying therapy 1

2. Assessing for axial involvement: Hip pain could indicate axial psoriatic arthritis, which may respond poorly to sulfasalazine 1

   • Consider imaging if axial involvement is suspected 3

3. Considering TNF inhibitors: If pain persists despite optimized conventional therapy, TNF inhibitors may be indicated 1

Common Pitfalls to Avoid

1. Overreliance on opioids: Avoid long-term opioid use for chronic non-cancer pain due to risks of dependence and other adverse effects

2. Inadequate disease modification: Focusing only on pain management without addressing underlying disease activity

3. Ignoring sleep hygiene: Pain management should be part of a comprehensive approach to improving sleep quality

4. Overlooking axial disease: Sulfasalazine has limited efficacy for axial symptoms; persistent hip pain may indicate need for different DMARD therapy 1

By implementing an NSAID at bedtime, specifically targeting the nighttime pain, the patient should experience improved pain control and better sleep quality while maintaining the current disease-modifying regimen.