National and Multinational Evidence-based Recommendations for Medical Pain Management in Inflammatory Joint Disease: Systematic Literature Research and Expert Opinion in the 3e Initiative

Background: In inflammatory joint disease, pain management is essential for sustaining the function of joints and maintaining the quality of life of affected patients. Beside disease modifying antirheumatic drugs and glucocorticoids for the treatment of inflammatory activity, pain medication is an important treatment module in the management of arthritis. It was the goal of this 3e (Evidence, Expertise, Exchange) initiative to develop evidence-based recommendations for pain management by pharmacotherapy. Materials and Methods: A total of 453 rheumatologists from 17 countries participated in the international 3e Initiative. The group of German experts comprised 66 participants. Using a Delphi process with 3 rounds of discussion, 10 international and 2 national clinical questions were selected regarding the use of pain medications in inflammatory joint disease. A systematic literature research (SLR) was performed in May 2010 for each question using Medline, EMBASE, Cochrane Library and the 2008/2009 EULAR/ACR abstracts. The national experts used the retrieved evidence to develop a set of national recommendations and assessed them for agreement and potential impact on clinical practice. Subsequently, the consensus recommendations were drafted. Results: A total of 49 242 references were identified, from which 167 studies were included in the systematic review. Based on this evidence, 12 recommendations and an algorithm for pharmacological management of pain were developed in response to the multinational questions. The recommendations related to the efficacy and safety of various analgesics, their use in different comorbidities and during pregnancy and lactation, the utility of pain measurement scales, as well as pain management. With regard to the 2 additional national questions, 34 out of 7 334 retrieved publications could be used to develop two recommendations on treatment monitoring and herbal medicine. Conclusion: 14 evidence-based recommendations and an algorithm on the management of pain by pharmacotherapy in inflammatory joint disease were developed.