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.

Fig. 1

Algorithm for pain management by pharmacotherapy in IA. The central column of the algorithm contains recommendations for the choice of medications for individuals with IA who experience pain despite optimal management of inflammation. It is recommended that clinicians first select an option from the top row, and move sequentially to lower rows when the options in each row are either ineffective or contraindicated. Adjuvant options may be introduced at any point in the algorithm, where appropriate. Each decision within the algorithm should be made with regard to the individual patient, including the points to consider in the left column. Level of evidence: 5. Grade of recommendation: D. Agreement 8.4/10.