Abstract

NEIRA, F.  and  ORTEGA, J. L.. Pain treatment in rheumatoid arthritis and evidence-based medicine. Rev. Soc. Esp. Dolor [online]. 2006, vol.13, n.8, pp.561-566. ISSN 1134-8046.

The objective has been the elaboration of a practical document, based on the best available scientific evidence, that allows physicians to adopt adequately founded diagnostic techniques and effective treatment in Rheumatoid Arthritis (RA). A systematic search in Internet has been made, using the term "rheumatoid arthritis" and "artritis reumatoide", in different groups of elaboration and storage of clinical practice quides: National Guideline Clearinghouse HTTP://www.guideline.gov/compares/compares.aspx, CMA infobase, Primary Care Clinical Practice Guidelines and Fisterra - Directory of Clinical Guides in Spanish. Guides of clinical practice (GPC) based in the evidence, meta-analysis and articles of greater relevance have been reviewed. RA is an inflammatory poliarthritis of undetermined aetiology, usually involving peripheral joints, with a symmetrical distribution. It affects functional and work capacity and increases mortality. The usual symptoms are arthralgia, morning stiffness, fatigue, weight loss and fever. It is considered that RA is present when 4 of the following 7 criteria are observed (American Rheumatism Association 1987): morning stiffness, arthritis in 3 or more joints, arthritis in joints of the hand, symmetrical arthritis, rheumatoid nodules, positive rheumatoid factor and radiological changes. Comprehensive measures, multidisciplinary treatment and occupational therapy are essential, level of evidence (NE) I. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective, recommendation (R) B. Tramadol and major opioids can be associated to NSAIDs when pain has not been properly controlled (R B). It is currently recommended to initiate the treatment with disease-modifying anti-rheumatic drugs (DMRADs): hydroxychloroquine, sulfasalazine, methotrexate, etanercept, leflunomide, gold salts, cyclosporine, azathioprine, infliximab, and ciclofosfamida. The combination of one or more of these drugs is effective and not more toxic than separately. Low doses of corticosteroids decrease the evolution of joint damage, but cannot be routinely recommended (R B). Intra-articular glucocorticoid injections can be of use for RA. Calcium, vitamin D and bisphosphonate are concomitantly used (R B). Surgical treatment is indicated when pain does not improve with medical measures and there is loss of function. Among RA complications are: carpal tunnel syndrome, rheumatoid vasculitis, cervical tract attacks and septic arthritis. Nutritional measures, occupational therapy (NE I), exercises, protection of the joints and psychotherapy (NE I) should not be neglected.

Keywords : Rheumatoid arthritis; Evidence-Based Medicine; Pain.

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