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RHEUMATOID ARTHRITIS AND JUVENILE
RHEUMATOID ARTHRITIS
Arthritis 101
RA and juvenile RA (JRA) are treated with an array of disease-modifying
agents that have secondary effects of relieving pain. The large number of
these agents precludes their discussion in detail here. This chapter will
address use of agents with a primary analgesic effect.
First-line analgesia for RA and JRA consists of NSAIDs. 56 More than 50% of
patients will have significant pain relief with the first NSAID chosen; half of the
remaining group will respond to a different NSAID. 56 There are few data supporting
the use of one NSAID over another, but the agents that are available in liquid
form (e.g. naproxen, ibuprofen, indomethacin) may be particularly useful in
younger patients with JRA. Naproxen has an additional advantage in its twicedaily
dosing; it can be administered to children in a BID regimen of 10–20 mg/kg
per dose (maximum daily dose 1000 mg). 56 The lowest effective dose should be
administered in order to minimize side effect risk. 56,57 Data from an RCT
demonstrated the utility of naproxen (500 mg PO BID), which provided pain
relief equivalent to that achieved with the COX-2 selective NSAID valdecoxib. 58
The excess coronary mortality in RA patients should heighten acute care
providers’ awareness of the potential for COX-2 selective NSAIDs’ cardiovascular
sequelae. 59 However, as is the case for OA, there is evidence that use of
COX-2 selective NSAIDs for RA is both effective and safe (i.e. fewer GI side
effects at no cost of increased cardiovascular problems). 36 When administered
at a dosage associated with relative COX-2 specificity, meloxicam (7.5–15 mg
PO QD) achieves equal pain relief and improved GI safety, compared with
diclofenac, piroxicam,ornaproxen. 60 Meta-analysis concluding that celecoxib
use incurred no significant cardiovascular risk increment (over placebo or
nonselective NSAIDs) included trial participants with RA. 12 There is, therefore,
some role for COX-2 selective NSAIDs in RA, particularly in patients with
significant potential for GI side effects; expert rheumatology reviews suggest
COX-2 selective NSAIDs are cost effective for patients at high risk of GI bleeding.
61 Acute care use of the COX-2 selective NSAIDs should be embarked upon
only with appropriate consideration (and discussion) of cardiovascular risk in
any patient; extra precaution is warranted in patients with RA.