Personal recommendations for management

Management of pain in RA requires a multidiscipli-nary team approach and early referral to secondary care is essential [64]. Confirmation of the diagnosis is by clinical assessment supported by simple investigations such as a measure of the acute phase response (CRP or plasma viscosity), measurement of rheumatoid factor (RF) and plain radiography of hands and feet. If there is diagnostic doubt (for example, if a positive RF is found but the patient is clinically atypical for RA, raising the possibility that the RF is false positive), measurement of anti-CCP antibodies and use of more sensitive methods to detect inflammation such as ultrasound of the small joints of the hand should be employed. NSAID should be started early, unless contraindicated. Confirmation of diagnosis should lead to aggressive therapy, with disease-modifying drugs being introduced if signs of inflammation persist 3 months after onset. My preferred drug is methotrexate, initially 7.5 mg weekly, increasing by 2.5 mg every month until disease control is achieved. Alternatives would be sulfasalazine 1 g bd. Prednisolone 7.5 mg daily with appropriate bone protection should be added for the first 2 years in all patients at high risk of progression and others in whom the inflammatory response is inadequately controlled.

Failure to respond to a DMARD (as measured by DAS) should trigger a switch to another DMARD. Failure of three or more DMARDs, alone or in combination, should result in anti-TNF therapy being initiated. Failure of one anti-TNF drug is followed by rituximab or a second anti-TNF drug.

On diagnosis, all patients should be assessed by a physiotherapist, occupational therapist and specialist nurse and the pain-controlling measures outlined above initiated. Surgical referral, ideally to a surgeon with a special interest in surgical management of RA, is undertaken as required.

Potential barriers to implementation of this algorithm include:

• delayed presentation by patients to primary care

• delayed recognition and referral from primary to secondary care

• centrally directed political constraints such as a move to place all rheumatology care in the community

• lack of provision of a multidisciplinary team

• lack of resources to monitor patients closely (essential if lack of response is to be picked up quickly and changes made)

• financial constraints on provision of drugs, especially biologic therapies

• lack of good patient-centered outcome measures.

Natural Pain Management

Natural Pain Management

Do You Suffer From Chronic Pain? Do You Feel Like You Might Be Addicted to Pain Killers For Life? Are You Trapped on a Merry-Go-Round of Escalating Pain Tolerance That Might Eventually Mean That No Pain Killer Treats Your Condition Anymore? Have you been prescribed pain killers with dangerous side effects?

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