Overview of pain management in rheumatoid arthritis

Note: Not all pain in RA is associated with a disease flare. Assess the person for signs of inflammation or alerting features (‘red flags’) that may suggest other serious pathology.

Pain is common in people with rheumatoid arthritis (RA), even when disease-modifying antirheumatic drugs (DMARDs) are used. People can experience significant joint pain, which may be associated with substantial disability; however, not all pain is associated with a flare of RA (ie increase in disease activity). Pain in RA may be associated with:

If a person with RA is experiencing severe or escalating joint pain, assess for any signs of disease flare, or alerting features (‘red flags’) that may suggest potentially serious conditions that require urgent management. Alerting features (‘red flags’) that may suggest serious pathologies in people with rheumatoid arthritis lists serious pathologies to exclude and ‘red flag’ features. Seek urgent specialist advice if any of the ‘red flag’ features are present.
Note: Seek urgent specialist advice if any of the ‘red flag’ features are present.
Figure 1. Alerting features (‘red flags’) that may suggest serious pathologies in people with rheumatoid arthritis.

[NB1]

People with rheumatoid arthritis (RA) who have severe or escalating joint pain may have a disease flare or other serious pathology (eg avascular necrosis of bone, fracture, infection, malignancy or vasculitis). If any of the following alerting features (‘red flags’) are present, urgent specialist referral for management is required.

Alerting features may include:

  • fever, weight loss, malaise
  • acute severe pain, particularly acute monoarthritis (different to usual RA pain)
  • focal or diffuse muscle weakness
  • history of significant trauma
  • night pain, neurogenic pain or claudication
  • rash or purpura.
Note: NB1: This list is not exhaustive.

Early diagnosis of acute inflammatory joint pain suggestive of a disease flare should be managed according to the patient’s individualised self-management plan until they can be reviewed by their specialist. Prompt referral to the specialist is important as specific management may avert or minimise permanent joint damage and disability.

Consider referring patients with persistent inflammatory joint pain, despite DMARD therapy, back to their specialist for adjustment of their DMARD regimen.

If pain is thought to be unrelated to a disease flare or persistent inflammatory joint pain, assess the pain severity (using a visual analogue scale or numerical rating scale), its impact, and its potential aetiology, all of which are important in guiding the most appropriate management.