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102 Arthritis
For breakthrough pain for patients taking NSAIDs, the combination of PO
tramadol (37.5 mg) and acetaminophen (325 mg) provides significant symp-
tom relief. 62 Mild side effects (e.g. dizziness, nausea) are relatively common,
but serious drug-related adverse effects are rare. 62 Meta-analysis of trials of
chronic pain relief, including RA patients, endorsed the conclusion that
opioid utility in this population is limited (owing to side effects) to short
courses for breakthrough pain. 26
Systemic or injected glucocorticoids are useful in RA and JRA. Although a
few weeks may be required to achieve maximal pain relief, intra-articular
methylprednisolone (40 mg) provides equal symptom relief to that
achieved with etanercept. 63 Pooled analysis of available data for RA and
JRA suggests that therapeutic efficacy of intra-articular corticosteroids may
be enhanced with immobilization of the knee after injection, but not the
wrist. 64 When more than one joint is involved, polyarticular injection of
corticosteroids appears to achieve better pain relief than a single IM
injection. 65
The NSAIDs are administered for analgesia only; they do not modify the
JRA or RA disease process. Other agents that do modify the disease process,
but are not appropriate for ED use owing to treatment complexity or complications,
include drugs such as biologics (e.g. etanercept), cytotoxins (e.g.
azathioprine), and antirheumatics such as methotrexate and sulfasalazine.
The pyrimidine synthesis inhibitor leflunomide, the omega-3 polyunsaturated
fatty acids, and the antibacterial agents levofloxacin and clarithromycin
have promise, but again their application is for longer-term therapy
(analgesic effects can take weeks). 66–69
n Summary and recommendations
CRYSTAL ARTHROPATHY
First line: NSAID (e.g. indomethacin 50 mg PO TID)
Reasonable: short-course COX-2 selective NSAID therapy (e.g. celecoxib
200 mg PO BID), if favorable GI/cardiovascular risk profile