Multinational evidence-based recommendations for pain management by pharmacotherapy in inflammatory arthritis: integrating systematic literature research and expert opinion of a broad panel of rheumatologists in the 3e Initiative

Abstract

Objective. To develop evidence-based recommendations for pain management by pharmacotherapy in patients with inflammatory arthritis (IA).Methods. A total of 453 rheumatologists from 17 countries participated in the 2010 3e (Evidence, Expertise, Exchange) Initiative. Using a formal voting process, 89 rheumatologists representing all 17 countries selected 10 clinical questions regarding the use of pain medications in IA. Bibliographic fellows undertook a systematic literature review for each question, using MEDLINE, EMBASE, Cochrane CENTRAL and 2008–09 European League Against Rheumatism (EULAR)/ACR 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. A total of 49 242 references were identified, from which 167 studies were included in the systematic reviews. One clinical question regarding different comorbidities was divided into two separate reviews, resulting in 11 recommendations in total. Oxford levels of evidence were applied to each recommendation. The recommendations related to the efficacy and safety of various analgesic medications, pain measurement scales and pain management in the pre-conception period, pregnancy and lactation. Finally, an algorithm for the pharmacological management of pain in IA was developed. Twenty per cent of rheumatologists reported that the algorithm would change their practice, and 75% felt the algorithm was in accordance with their current practice.Conclusions. Eleven evidence-based recommendations on the management of pain by pharmacotherapy in IA were developed. They are supported by a large panel of rheumatologists from 17 countries, thus enhancing their utility in clinical practice.

Limitations in the Full Reporting of Systematic Literature Review

“…Our paper summarizes the recommendations and constitutes the most practical comprehensive consensus for the practicing physician. Our paper is similar to other published recommendations involving multiple clinically relevant questions such as those in the 3e Initiative in Rheumatology 8,9,10,11,12 . Likewise, the 3e initiative led to subsequent publications detailing the most relevant clinical questions and findings.…”

Rheumatoid Arthritis: A Brief Overview of the Treatment

“…Whittle et al [15] addressed the question of the use of opioid analgesics for patients with pain due to RA. From their conclusions, weak opioids such as codeine, dextropropoxyphene, and tramadol may play an effective role in the short-term management of pain caused by RA, but the adverse effects outweigh the benefits.…”

Pain in systemic inflammatory rheumatic diseases

“…It may be due to active inflammation or joint damage arising from previous inflammation and tissue destruction, but it is frequently multifactorial in origin and has both central and peripheral components [34]. Treatment with DMARDs and NSAIDs reduces the inflammatory pain symptoms [35], although the fact that many patients continue to experience moderate pain [36,37] suggests the existence of a non-inflammatory component with a different aetiology and/or alterations in central pain regulation mechanisms [38].…”

“…The main cause of diagnostic confusion relating to the 1990 ACR criteria [66] was the overlap between SpA-related enthesitis and FM-related tender points (TPs); the latter were therefore replaced by patient self-assessment in the 2010 ACR FM diagnostic criteria [30], but some confusion remains [67]. Although pain is a cornerstone of AS, it does not necessarily reflect increased inflammatory disease activity [34], and sometimes it seems to be more related to a mechanism of central pain sensitisation similar to that observed in FM [35]. However, it is difficult to assess widespread pain in AS patients because of the presence of enthesitis and tenosynovitis [31,32] and, as tendon insertion sites are located throughout the body, it is not always clear whether the pain is related to disease activity or reflects an associated pain syndrome.…”