Arthritis pain guidelines raising some eyebrows

May 6, 2002

American Pain Society recommends using OxyContin to treat patients with arthritis.

Pharmacists will find oxycodone making headlines once again. This time, however, it is as a recommended drug of choice for patients with severe arthritis pain unrelieved by other methods.

This recommendation and others were set forth at the American Pain Society (APS) annual scientific meeting held in March. The association introduced its first set of clinical guidelines for the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. An interdisciplinary panel of physicians, nurses, and pharmacists, with a common interest in pain, developed the guidelines to assist healthcare professionals treating arthritis patients. Earlier APS publications include guidelines for managing pain in other conditions, such as cancer and sickle cell disease.

According to the guidelines, opioids, such as oxycodone and morphine, should be used in patients with severe arthritis pain when COX-2 inhibitors and other nonsteroidal anti-inflammatory drugs do not provide adequate relief. "Opiates can and should play a role in treating severe arthritis pain," said Don Miller, Pharm.D., professor and chair of pharmacy practice at North Dakota State University's College of Pharmacy.

"There is good evidence that patients do not escalate long-term doses of oxycodone if they are properly selected," said Miller, who is also a member of the editorial advisory board for Arthritis Today, a consumer magazine published by the Arthritis Foundation. Ideal candidates are individuals with severe pain unrelieved by other methods, having a strong relationship with their physician and pharmacist, and with no history of substance abuse or psychological dependence, he explained.

Perhaps the most surprising new recommendation from APS—and one that sets it apart from existing guides from other arthritis organizations—is the use of COX-2 selective NSAIDs, such as Celebrex (celecoxib, Pharmacia), Vioxx (rofecoxib, Merck), and Bextra (valdecoxib, Pharmacia), as the drugs of choice for treating moderate to severe pain in osteoarthritis and rheumatoid arthritis.

"This is where I disagree with the APS guidelines," said Miller. Two randomized trials, VIGOR (Vioxx Gastrointestinal Outcomes Research Study) and CLASS (Celecoxib Long-Term Arthritis Safety Study), both conducted by the drug's manufacturers to demonstrate superior GI safety over the nonselective NSAIDs, adequately established an advantage for COX-2 inhibitors in reduced GI bleeding, he noted. However, they did not show they were more effective for treating arthritis pain. Furthermore, results from the VIGOR trial showed the Vioxx group had an increased relative risk of developing a cardiovascular event, compared with the group taking naproxen.

Researchers examined the results of the VIGOR and CLASS studies and concluded that more investigation was necessary to determine the exact cardiovascular effect of the COX-2 inhibitors. As part of the new guidelines, APS does recommend that patients taking selective or nonselective NSAIDs, who are at risk for cardiovascular events, also receive low-dose aspirin. However, the CLASS trial results showed most of the GI safety of celecoxib was eliminated in persons taking concurrent low-dose aspirin. This finding could potentially weaken the APS recommendation to use COX-2 inhibitors as the drugs of choice for moderate to severe pain.

The relatively high cost of the COX-2 inhibitors is another concern. "I don't think you can ignore cost in today's world," Miller said. The APS guidelines suggest that arthritis pain sufferers may benefit from nonselective NSAIDs taken along with another drug to help alleviate GI distress, when cost is an issue. Miller said he would continue recommending the use of nonselective NSAIDs for patients at low risk for GI bleeding.

Another interesting recommendation is the APS statement that adults with osteoarthritis should be encouraged to take 1,500 mg of glucosamine daily. "I don't absolutely disagree with the recommendation, but I think it is overly broad and sure to surprise many physicians," Miller said.

Acetaminophen is the drug therapy of choice for all patients with mild to moderate arthritis pain because of its favorable safety profile and low cost. For children with juvenile chronic arthritis, APS recommends using the same drug therapy as adults and following appropriate measures to minimize the pain and anxiety associated with medical procedures.

According to APS, assessment of the pain (type, source, and impact on functioning), education of the patient and family, behavioral interventions, physical activity, weight management, physical and/or occupational therapy, dietary supplements, and drugs all play a role in managing arthritis pain. Surgical referrals should be made when drug therapy is no longer effective and the patient's ability to function is so severely impaired that physical activity is impossible.

Pharmacists can order a complete set of the APS guidelines, Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis, on the American Pain Society Web site at www.ampainsoc.org .