Pain Treatment In Rheumatoid Arthritis
Pain is a serious problem in rheumatoid arthritis and can adversely impact quality of life, functioning and sleep.
In studies measuring the amount of pain that people with RA experience, with approximately 80% suffering from moderate or severe episodes of pain in the last 2 months. Almost two thirds were unhappy with the amount of pain they experienced, and rates of depression were proportional to the severity of pain. Pain relief was important, particularly in the USA, where it was patients’ top aim in taking medication.
Thankfully there are some measures that can be used to reduce pain.
The first line of treatment for RA is usually paracetamol/acetaminophen (e.g.Tynelol) or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (e.g. Advil), naproxen (e.g. Aleve), aspirin (e.g. Buffer) or a COX-2 inhibitor, for instance celecoxib. Occasionally, you may be prescribed drugs for nerve pain, such as gabapentin (e.g. Neurontin).
Paracetamol is relatively safe and effective for mild to moderate pain. It can damage the liver if taken in overdose. Sometimes it may be combined with an opioid such as codeine. NSAIDs are also effective and have anti-inflammatory actions. However, they can cause gastrointestinal bleeding and kidney failure. The COX-2 inhibitors do not cause stomach side-effects but one, rofecoxib, was withdrawn due to concerns over an increased risk of heart attacks.
Opioids are derivatives of morphine and are moderate to strong painkillers. Examples include codeine (e.g. Panadeine Forte), tramadol (e.g. Tramal), tilidine (e.g.Tilidin), pentazocine (e.g. Talwin) and morphine (e.g. Duragesic). A clinical trial found that even weak opioids such as tramadol and codeine were effective in reducing pain over a few weeks, although they did have more side effects than placebo. These included constipation, vomiting and increased fatigue.
In the study, 18% of those treated with opioids found a good or very good improvement in six weeks. 57% of the opioid groups reported good or very good improvements by the end of the study compared with 40% in the group given placebo. Approximately 15% withdrew in both groups due to side effects or insufficient pain relief.
DMARDs and biologic agents (BMARDs) can also help to reduce pain by dampening down inflammation and joint destruction. Methotrexate is the primary DMARD, but others include leflunomide and gold. DMARDs may be required in combination, such as COBRA therapy (methotrexate, sulfasalazine and prednisolone or hydroxychloroquine). However, combination therapy has not been shown to be more effective than monotherapy (one drug only) in treating pain.
Most of the BMARDs have similar effectiveness. The anti-TNF group were the first to be developed and include etanercept, infliximb, adalimumab and golimumab. Other non-TNf drugs are abatacept, anakinra and rituximab. Both are usually combined with methotrexate, a folate inhibitor which acts on the DNA of cells in the joints.
A recent study looked at certolizumab pegol, an anti-TNF monoclonal antibody, and its effects on rheumatoid arthritis progression. After 24 weeks, 45.5% of patients had responded to certolizumab with improvements in pain compared to only 9.3% in the placebo group. The side effects were mainly moderate and tolerable.
There may be barriers which get in the way of good pain management. These are common, occurring in over half of RA patients. They can include concerns regarding the overuse of medications, particularly opioids. However, the risk of you becoming dependent on these drugs is not high if they are taken for their proper use. Other barriers are a fear or dislike of side effects, an unwillingness to take too many pills and worries about masking serious symptoms. Good educational material and discussions will help to overcome these barriers.
Some doctors may also experience barriers to prescribing painkillers for patients with RA. These include a lack of knowledge regarding certain medications, the fear of tolerance or addiction occurring, insufficient assessment of pain and habits as to what they had previously prescribed.
There are sometimes barriers for caregivers looking after those with RA. Many of these overlap, for instance fears of side effects, dependence or the use of strong painkillers being a sign of serious or progressive disease. If a family member has questions, you may wish to bring them along with you to your next medical appointment.
Psychological therapies such as cognitive behavioral therapy and relexation techniques can help you to deal with the pain of RA. These include pain coping skills, disclosing emotions and family involvement. For more information, see the page on psychological treatments.
One study looked at the effects of physical activity on pain scores in RA. Patients with a higher self-efficacy, specified action plans and defined goals were more likely to achieve those goals. This group reported lower pain scores and better quality of life.
This video describes pain in rheumatoid arthritis and some useful ways to combat this.
1. Knittle K, et al. Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis. Arthritis Care and Research. 2011 Nov;63(11):1613-1619.
2. Whittle S, et al. Opioid therapy for treating rheumatoid arthritis pain (Review). Cochrane Database of Systematic Reviews. 2011:11.
3. Fleischmann, et al. Efficacy and safety of certolizumab pegol monotherapy every 4 weeks in patients with rheumatoid arthritis failing previous disease-modifying antirheumatic therapy: the FAST4WARD study. Ann Rheum Dis 2009;68:805-811.
4. Smith H, et al. Painful rheumatoid arthritis. Pain Physician. 2011 Sept-Oct;14(5):E427-58.
5. Keefe F, et al. Psychological approaches to understanding and treating arthritis pain. Nature Reviews Rheumatology. 2010 Apr;6:210-216.