Pharmacological strategies for residual noninflammatory joint pain in rheumatoid arthritis

When analgesia is indicated for residual noninflammatory joint pain, the primary goal is to reduce pain intensity, thereby improving function and minimising disability. Before escalating analgesia, consider and address biopsychosocial and environmental factors that may be contributing to the patient’s experience of pain. Escalating the dosage of analgesia or introducing multiple drugs may increase the risk of harms without additional benefit.

If there are no signs or symptoms of inflammation, systemic corticosteroids are not recommended for the routine management of residual pain in patients with RA.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for mild to moderate pain in RA. All of the NSAIDs listed below are equally effective and drug choice should be based on patient factors (eg comorbidities); see Choosing an NSAID for advice on drug choice. If an oral NSAID is indicated for pain associated with RA, use:

1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib

OR

1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib

OR

1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen

OR

1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin

OR

1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen

OR

1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam

OR

1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen

OR

1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen

OR

1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam

OR

2diclofenac 25 to 50 mg orally, 2 to 3 times daily until symptoms subside. diclofenac diclofenac diclofenac

The potential benefits of an NSAID should be weighed against its potential harms, particularly in patients at high risk of harms; see Principles of NSAID use for musculoskeletal conditions for more information.

If neuropathic pain or fibromyalgia are thought to be contributing significantly to a person’s pain, consider adding specific analgesic therapy for these conditions; see:

For people with severe refractory pain, consider referral to a rheumatologist or specialist in pain management. Structural joint damage, or coexistent osteoarthritis with RA, may require an orthopaedic surgical opinion regarding joint replacement surgery.

An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis: Opioids for pain in rheumatoid arthritis1 does not recommend the routine use of opioids for the treatment of pain in RAAustralia & New Zealand Musculoskeletal Clinical Trials Network (ANZMUSC), 2023. Short-acting opioids have a very limited role in RA and should only be used briefly for severe pain when other analgesic options have failed. This is because of modest (if any) benefits and a significant risk of harms; see Drugs that have limited use in the management of musculoskeletal pain for more information on the use of opioids.

1 Australia and New Zealand Musculoskeletal Clinical Trials Network (ANZMUSC). Opioids for pain in rheumatoid arthritis. An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. 2022 [version 2.8]. Accessed March 2023. Available from [URL].Return