CHAPTER 41: Pain Management in Medical Rheumatologic Diseases

INTRODUCTION

Pain is the most common presenting symptom in rheumatologic diseases. Pain is what brings patients to seek medical attention. It interferes with their mental and physical wellness as well as their quality of life.

A study of the U.S. adult population estimated the prevalence of “self-reported doctors-diagnosed arthritis” to be at 21% (46.4 million persons). Among those, 27 million were estimated to have osteoarthritis, 3 million to have gout, and 1.3 million to have rheumatoid arthritis.^1,2

There are certain principles that will help guide clinicians in the general management of arthritis pain:

1. Diagnose correctly the underlying etiology of the pain such as rheumatoid arthritis (RA) versus osteoarthritis (OA), and distinguish rheumatic diseases from nonmusculoskeletal sources of pain such as neuropathies or somatic etiologies. Recognize that there could be an overlap among different disorders at times, and pain could be of multifactorial etiology. This will influence which approaches to choose to treat the underlying diseases and the ensuing pain.

2. Almost always treat the underlying disease first and consider consulting a rheumatologist. For example, starting a disease-modifying anti-rheumatic drug (DMARD) in rheumatoid arthritis will alleviate the inflammation and, thus, the pain.

3. When the underlying disease is amenable to treatment with other long-term measures, employ pain management as a bridge therapy until achieving long-term disease control (i.e., controlling the activity of RA with DMARDs or preventing gout attacks with uric acid–lowering agents).

4. Consider nonpharmacological interventions such as physical therapy; orthotics, if indicated; and safe, potentially effective, alternative therapies, and address other comorbidities such as obesity.^3-7

5. Keep in mind the potential treatment side effects, consider the individual risk factors, and thrive to prevent those side effects.

6. Pay more attention to potential treatment-related complications in the elderly population.⁸ Always ask the question, “Do the benefits really outweigh the risks?”

7. Consider starting with milder agents and low doses initially, as patients respond differently to medications. (See Table 41-1.)

While this chapter will focus on the management of pain in OA and RA, the same concepts apply for joint pain in other rheumatic diseases. The administration and management for narcotics and treatment of pain in fibromyalgia are beyond the scope of this chapter and are covered elsewhere in this textbook.

NONPHARMACOLOGIC THERAPY IN OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Nonpharmacologic approaches depend on the site of OA and include patient education, self-management and exercise programs, physical and ...