Appendix K

National Guideline Clearing House™ (an initiative of the Agency for Health care Research and Quality (AHRQ)) Summary of the Major Recommendations of the American Pain Society’s

"GUIDELINE FOR THE MANAGEMENT OF PAIN IN OSTEOARTHRITIS,
RHEUMATOID ARTHRITIS AND JUVENILE CHRONIC ARTHRITIS"

Note: These recommendations are presented in abbreviated form. Readers should refer to the text of the guideline document for a detailed discussion of each of the following topics. This guideline can be obtained at the American Pain Society Website, http://www.ampainsoc.org/pub/arthritis.htm

Definitions for the type of evidence (I, II, III, IV, V) and the strength and consistency of evidence grades (A, B, C, D, Panel consensus) are provided at the end of the Major Recommendations field.

Pain Assessment

  1. Treatment of people with arthritis should include, in addition to a complete history and physical examination, an initial comprehensive pain assessment and ongoing assessment of pain and functional status to identify, implement, and evaluate effectiveness of pain interventions. Pain assessment should focus on the type and quality of pain, source, intensity, location, duration/time course, pain affect, and effects on personal lifestyle. (Panel consensus)
  2. Self-report should be the primary source of pain assessment when possible. Behavioral observations and physiologic measurements may provide additional information but should not be used as the primary source of pain assessment. Exceptions are preverbal children and nonverbal and cognitively impaired individuals, for whom behavioral observation should be the primary source for pain assessment. (B)
  3. Selection of an appropriate pain assessment tool should take into consideration the person’s cognitive development, language, culture, and preferences. Use the same pain assessment tool for the person on subsequent assessments to facilitate reliable evaluations of changes in the pain. (B)
  4. Because pain is a major cause of disability in people with arthritis, assessment of functional status should be included in the pain assessment. When selecting a functional status measure, consideration should be given to the cognitive-developmental abilities of the person, the type of practice setting, the domains of function to be assessed, and the time and resources needed to complete the assessment. (B)
  5. When arthritis pain is persistent or severe, the clinician should conduct a comprehensive assessment, including an evaluation of biological, psychological, or social factors that may be contributing to pain as well as an assessment of the overall impact of pain on function. (Panel consensus)

Management of Pain in Osteoarthritis and Rheumatoid Arthritis
Patient/Family Education and Cognitive Behavioral Interventions

  1. A patient’s thoughts, feelings, emotions, and behavior, and his or her family’s response, can influence the arthritis pain experience. Therefore, education about pain, pain management options, and self-management programs should be communicated to the patient and family as an integral and cost-effective part of treatment. (A)
  2. Cognitive-behavioral therapy (CBT) should be used to reduce pain and psychological disability and to enhance self-efficacy and pain coping. (B)

Pharmacological Management of Pain in Osteoarthritis and Rheumatoid Arthritis

  1. Analgesic and antiinflammatory medications are important in arthritis pain management but should be
    used concurrently with nutritional, physical, educational, and cognitive-behavioral interventions. (A)
  2. Clinicians should consider efficacy, adverse side effects, dosing frequency, patient preference, and cost in selecting medication for pain management. (Panel consensus)
  3. For the person with osteoarthritis (OA), acetaminophen is the medication of first choice for mild pain. There is little evidence that acetaminophen provides any benefit when peripheral inflammation is a causative factor for the pain. (A) For the person with moderate to severe pain and or inflammation, a cyclooxygenase-2 (COX-2) selective nonsteroidal antiinflammatory drug (NSAID) is the first choice, unless the person is at significant risk for hypertension or renal disorder. (B) In persons at increased risk for hypertension and edema, clinicians should use any NSAID cautiously due to the risk of exacerbating hypertension or edema. Nonselective NSAIDs should be considered only if the person is not responsive to or not able to take COX-2 selective NSAIDs and/or acetaminophen up to 4,000 mg per day, and only after a risk analysis is done to determine the risk for a significant NSAID-induced gastrointestinal (GI) complication. If such risk factors exist, then a prophylactic agent such as a proton pump inhibitor or misoprostol should be given along with the nonselective NSAID. (B) The person at risk for a cardiovascular event should be given a regular low dose of aspirin (between 75 mg-160 mg per day), whether the patient is treated with a nonselective or COX-2 selective NSAID. (B)
  4. The injection of intra-articular glucocorticoids should be considered in those persons with OA who have significantly increased and inflammatory flare or extensive inflammation in one or a few joints. Intra-articular glucocorticoids can be administered at any time during the course of the illness. (B) Systemic glucocorticoids should not be used in persons with OA. The injection of hyaluronic acid supplements into the knee may be considered in persons with OA and knee pain who are unresponsive to acetaminophen, nonselective, and COX-2 selective NSAIDs, or who cannot take these medications. Hyaluronic acid can be administered at any time during the course of the illness. (B)
  5. Tramadol may be used alone or in combination with acetaminophen or NSAIDs for therapy at any time during the treatment of a person with OA when NSAIDs alone produce inadequate pain relief. (C)
  6. For the person with active rheumatoid arthritis (RA), disease-modifying antirheumatic drugs (DMARDs) are the first choice of pharmacotherapy. (B, C) For the person who is receiving any of the five known DMARDs shown by radiograph to slow damage from disease progression (sulfasalazine, methotrexate, leflunomide, etanercept, and infliximab as of this writing), acetaminophen may be used as a concomitant medication for mild pain. (A) However, because RA is an inflammatory disease, many more patients will benefit from concomitant therapy with an antiinflammatory medication. A COX-2 selective NSAID should be used as a concomitant medication for the person with moderate to severe pain with or without inflammation, unless there are clear risk factors for exacerbation of renal disease or the medications are not tolerated due to GI complications. (B) If the antiinflammatory medication and the DMARD provide inadequate pain relief, then acetaminophen should be added. (B) If gastrointestinal (GI) risk factors exist, then a prophylactic proton pump inhibitor or misoprostol should be given along with the nonselective NSAID. The person at risk for a cardiovascular event should be given a regular low dose of aspirin (between 75-160 mg per day), whether treated with a nonselective or a COX-2 selective NSAID. (B)
  7. Low-dose oral glucocorticosteroids (less than 15 mg per day of prednisone or equivalent as a single dose) should be considered for short-term use in persons with RA. These medications have been shown to decrease progression of erosions for the first 2 years. When oral glucocorticoids are used, prophylaxis with a bisphosphonate, along with calcium supplementation and daily supplemental vitamin D to lower the risk of glucocorticoid-induced osteoporosis, should be considered. (B)
  8. Intra-articular glucocorticoids should be used in patients with intense flares of OA or RA as evidenced by high degrees of inflammation and effusion in the joint; they can be used at any time during the course of the illness. (B)
  9. Opioids should be used for patients with OA or RA when other medications and nonpharmacologic interventions produce inadequate pain relief and the patient’s quality of life is affected by the pain. (B) Morphine, oxycodone, hydrocodone, or other mu agonist opioids, as a single agent or combined with an NSAID or with acetaminophen, should be used for moderate to severe OA or RA pain that has not responded to other treatments. (B) The use of codeine and propoxyphene should be avoided because of their side effects and limited analgesic effectiveness. (B)

Dietary Supplements and Nutrition

  1. Adults with OA should be encouraged to take 1,500 mg of oral glucosamine sulfate daily. (A)
  2. People with arthritis should be advised to maintain an ideal body weight and adhere to a balanced diet containing adequate amounts of protein, fat, vitamins, and minerals. Adults should lose weight if their body mass index (BMI) is greater than 30, and follow a weight management program. Children should lose weight if their BMI is greater than the 95th percentile for children of the same age and gender. (B)

Exercise and Physical Modalities in the Management of Arthritis Pain

  1. All individuals should be encouraged and supported to participate in the minimum level of physical activity recommended by the U.S. Surgeon General (1996). Participate in at least 30 minutes of moderate physical activity on most days of the week. (B)
  2. People with OA, RA, or juvenile chronic arthritis (JCA) who have difficulty in maintaining minimum levels of physical activity should be referred to appropriate conditioning exercise opportunities in the community and their progress followed routinely by the health care team. When necessary to prepare an individual for successful participation in a community-based or self-directed exercise program, referral should be made for physical therapy and/or occupational therapy to evaluate and reduce impairments in range of motion, flexibility, strength, and endurance and instruct in joint protection strategies. (B)

Surgical Intervention

  1. For optimal functional results, people with disabling arthritis should be referred for surgical care prior to the onset of joint contracture, severe deformity, and advanced muscular wasting and deconditioning rather than as a last resort. (B)
  2. Unless there are medical contraindications, most people with arthritis, including obese and older persons, should be referred for surgical treatment when noninvasive treatment is ineffective and function is impaired. (B)
  3. Surgical intervention should be considered when pain and functional limitations prevent the minimum amount of activity recommended by the U.S. Surgeon General (30 minutes of exercise on most days of the week to maintain cardiovascular health). (B)

Treatment of Pain in Children and Older Adults with Arthritis

  1. The assessment of pain should be ongoing in any child with JCA. A comprehensive and developmentally appropriate pain assessment should incorporate a pain history, the child’s self report, behavioral observations, parents’ assessment, and physiologic cues. (Panel consensus)
  2. Analgesia for children should be similar to that for adults who experience pain. (Panel consensus)
  3. Patient/family education should be provided on an ongoing basis to increase self-care skills and feelings of self-efficacy and to develop self-advocacy skills for negotiating with the health care system. (Panel consensus)
  4. Cognitive-behavioral therapy (CBT) should be used to reduce pain and psychological disability and to enhance self-efficacy and pain coping for children. (B)
  5. Appropriate interventions to minimize pain and anxiety related to diagnostic and therapeutic procedures should be an integral part of the management of children with arthritis. The child and parent should be adequately prepared for any procedure, and interventions should be individualized for the child and the procedure and administered prophylactically. (B)
  6. Whenever conscious or deep sedation is required to perform any procedure, the guidelines developed by the American Academy of Pediatrics for patient monitoring and resuscitative equipment should be followed. (B)
  7. The antiinflammatory and analgesic benefits of nonsteroidal antiinflammatory drugs (NSAIDs) should be weighed against the potential risk, particularly in older people. In the person who is at increased risk for a serious upper gastrointestinal (GI) adverse event, gastroprotective agents should be used even if nonselective agents are given at low doses. (B)

Definitions

  • Therapies
    1. Meta-analysis of multiple well-designed controlled studies.
    2. Well-designed experimental studies.
    3. Well-designed, quasi-experimental studies, such as nonrandomized controlled, single-group pre-post, cohort, time series, or matched-case controlled studies.
    4. Well-designed nonexperimental studies, such as comparative and correlational descriptive and case studies.
    5. Case reports and clinical examples.
  • Strength and Consistency of Evidence
    1. There is evidence of type I or consistent findings from multiple studies of types II, III, or IV.
    2. There is evidence of types II, III, or IV, and findings are generally consistent.
    3. There is evidence of types II, III, or IV, but findings are inconsistent.
    4. There is little or no evidence, or there is type V evidence only.

Panel Consensus: Practice recommended based on the opinions of experts in pain management.
CLINICAL ALGORITHM(S) The original guideline contains algorithms for 1) The Management of Pain in Osteoarthritis; 2) The Management of Pain in Rheumatoid Arthritis; 3) The Management of Pain in Children with Arthritis.

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