Background Pain control is a mainstay in the management of rheumatic diseases. Although systematic clinical practice guidelines for pain management in Rheumatoid Arthritis (RA) are currently lacking, there are several evidence-based expert recommendations provided by rheumatologists from the 3e initiative1 – a multinational collaboration to help address clinical problems in the field of rheumatology.
Objectives Identify patient-reported pharmacotherapy regimens involved in the management of rheumatic pain based on the recommendations provided by the 3e initiative and compare the Rheumatoid Arthritis Disease Activity Index (RADAI) score and pain scores (HAQ pain score and RADAI joint pain score) within these regimens.
Methods Patient-reported data was collected from the Ontario Best Practices Research Initiative (OBRI), a clinical registry of RA patients followed in routine care. Patients receiving at least one pain medication at cohort entry or who reported starting a new pain medication while in the OBRI were selected (N=1,816) and followed till a change in their pain therapy was reported. Patient demographics were determined and patients receiving NSAIDs, acetaminophen, opioids, antidepressants and neuromodulators were selected as recommended by the 3e initiative (N=1,389). From these medication classes, common pharmacotherapy regimens were identified and the number of patients receiving each regimen were determined. Within each regimen, the RADAI score (0-10), RADAI joint pain score (0-10) and HAQ pain score (0-3) were calculated and compared. Standard error for each category was also calculated. Mean scores were calculated for patients who reported to be on the same pharmacotherapy regimen over several OBRI study visits.
Results Among 1,816 RA patients, the mean age was 57.6 years, the mean disease duration was 8.98 years and 78.9% were female. From our patient cohort receiving recommended medication therapy (N=1,389), 599 patients received NSAID monotherapy (43.1%), 192 received NSAIDs + acetaminophen (13.8%), 126 received NSAIDs + opioids (9.07%), 125 received acetaminophen monotherapy (9.00%) and 102 received NSAIDs + antidepressants (7.34%). 245 patients received other pharmacotherapy combinations (17.6%). Mean HAQ pain, RADAI joint pain and RADAI score for each pharmacotherapy regimen is shown in figure 1.
Conclusions NSAID monotherapy seems to be the most prevalent regimen for management of rheumatic pain. Patients receiving NSAID monotherapy report the least pain based on HAQ and RADAI joint pain assessments whereas patients receiving NSAIDs + opioids report the most pain. Similar trends are seen with disease activity based on the RADAI score. The use of opioids in RA may only be reserved for patients with severe pain resulting in higher pain and RADAI scores. Patient non-compliance due to adverse drug effects, inadequate education on the appropriate use of opioids, and the negative stigma surrounding their use may also play a role. Pharmacotherapy for pain management may also be influenced by the use of disease-modifying antirheumatic drugs and biologic molecules. Future work is required to identify these associations.
Whittle SL, Colebatch AN, Buchbinder R, et al. Rheumatology 51;2012:1416-1425.
Disclosure of Interest None declared