Pain is the most common symptom in rheumatoid disease and still presents a major therapeutic challenge.

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting approximately 1% of the population, characterised by symmetric, usually erosive, arthritis of the synovial joints and variable extra-articular features. Patients with RA should be managed jointly with a rheumatologist and have access to the specialised multidisciplinary team.

NICE have issued clinical guidance on the management of rheumatoid arthritis (CG79). Urgent referral for specialist opinion is required for suspected persistent synovitis of unknown cause, if any of the following apply:

• small joints of hands or feet affected
• more than one joint affected
• delay of 3 months or longer between onset of symptoms and seeking medical advice
• a positive MCP and MTP squeeze test is present and inflammatory arthritis is suspected

Refer even if blood tests show a normal acute-phase response or negative rheumatoid factor.

The RD&E hospital rheumatology department runs a weekly consultant-led early synovitis clinic.

Drug management aims to relieve symptoms and to modify the disease process. This section deals primarily with pain relief. Management of a flare is also covered. Disease modifying anti-rheumatic drugs (DMARDs) form the basis of treatment of rheumatoid arthritis. In addition to improving disease outcomes, they have an important role in controlling symptoms. The Shared Care Guidelines on the prescription and monitoring of DMARDs are available on the One Devon website. Safety information on methotrexate is included in this section. Please note there are multiple documents on this page, ensure you select the correct Shared Care Guideline (by specialty and locality).

Therapeutic options for pain relief in RA may include one or a combination of the medications listed below.

• Paracetamol
• Centrally acting agents – opioids, non-opioid analgesics, antidepressants
• NSAIDs/COX-2 inhibitors
• Corticosteroids – oral, intra-articular or parenteral

Before prescribing, ask whether the pain reported is due to active inflammatory disease, old damage or neuropathic pain?

• Evaluate symptoms and signs of active disease – joint pain and swelling, duration of early morning stiffness (EMS) and fatigue.
• May need to include levels of acute phase response, evidence of radiographic damage and the functional status of the patient.

Managing a flare of rheumatoid arthritis

A flare:

• is a sustained increase in the activity of arthritis characterised by pain, swelling, stiffness and constitutional symptoms;
• may be related to the inherent disease process or provoking factors such as intercurrent infection, surgery, medication withdrawal and psychological stress

1. Conservative measures: rest, pace activity, continue with ROM exercises, use splints.
2. Start or increase simple analgesia and NSAIDs.
3. Increase dose of DMARDs if appropriate.
4. Local joint injections.
   1. Consider a 'pulse' of steroid only if persistent pain and disability present.
   2. Depo-Medrone 80-120mg I/M.
   3. Prednisolone 15-20mg, reducing over two weeks.

NSAIDs and COX-ll inhibitors in rheumatoid arthritis

NSAIDs and COX-ll inhibitors are similar in efficacy in the treatment of rheumatoid arthritis. If they are not providing satisfactory symptom control, a review of DMARD or biological drug therapy may be required.

Periodic review of patients is required to determine whether risk factor status has changed and whether current treatment remains optimal.

Centrally acting analgesics in rheumatoid arthritis

Some patients may find weak opioids helpful. There is a synergistic effect of NSAIDs with weak opioids in musculoskeletal pain. Co-prescription of these (or paracetamol) may allow a lower dose of an NSAID to be used.

Tramadol may be better tolerated in some patients but is not a better analgesic than opioids.

Amitriptyline (start at 10mg at night and increase up to 50mg) has an analgesic effect independent of its antidepressant properties. This is likely to be shared with other antidepressants acting on serotonergic and noradrenergic pathways but not by SSRIs.

Corticosteroids in rheumatoid arthritis

Low dose steroids are often given orally or as an intramuscular injection of slow release compounds. They may be useful to achieve better symptomatic control or as bridge therapy before the onset of action of DMARDs.

For information on corticosteroids, see section 6.3 Corticosteroids 

Intra-articular corticosteroid injections are not associated with significant systemic adverse effects and are used to control inflammation in troublesome joints. Please see general notes on local and intra-articular steroid injections.

DMARDs

In addition to symptomatic treatment, most patients with RA require therapy with DMARDs. Shared care guidelines for these are available on the One Devon website.

Local and intra-articular injections

A practitioner should be trained in injection therapy and competent in the assessment and management of rheumatic disease to be able to administer intra-articular and soft tissue injections.

Intra-articular injection of long-acting steroid can give rapid, effective but temporary relief of pain (acts within 24 hours, lasts 2-6 weeks).

Examples of preparations and their doses

Bold indicates preferred preparation and dose

Soft tissue injection e.g. carpal tunnel

• Hydrocortisone 10-25mg
• Triamcinolone acetonide 10mg
• Methylprednisolone acetate 20mg

Small e.g. MCP, 1st CMC

• Hydrocortisone 25mg
• Triamcinolone acetonide 10-20mg
• Methylprednisolone acetate 20-40mg

Medium e.g. wrist, ankle

• Triamcinolone acetonide 20-40mg
• Methylprednisolone acetate 40mg

Large e.g. knee, shoulder

• Triamcinolone acetonide 40-80mg
• Methylprednisolone acetate 40-80mg