Pain relievers (analgesics)

Several different types or classes of drugs (apart from non-steroidal anti-inflammatory drugs) are used for pain relief in RA but do not have any effect on inflammation. These include analgesics such as acetaminophen or paracetamol (Tylenol), the narcotic-like pain medication tramadol (Ultram), antidepressant medications, neuromodulators (including anticonvulsants, capsaicin cream or ointment, and other agents), muscle relaxants, and narcotic pain relievers, such as codeine, oxycodone, and hydrocodone.1



Acetaminophen (paracetamol, brand name: Tylenol) is a mild analgesic that is available over-the-counter. A review of studies of the effectiveness of acetaminophen in relieving pain in patients with RA found only weak evidence in support of the benefit of acetaminophen used alone. It did appear to have an additive benefit in relieving pain when taken with an NSAID.2



Tramadol (Ultram) is a prescription narcotic-like analgesic used to treat moderate to severe pain. Tramadol is typically taken every 4 to 6 hours, as needed. It may be taken with or without food. It is also available in an extended-release formulation for patients who need continuous pain relief through the night. It is sometimes taken in a fixed-dose combination (as a single pill) with acetaminophen (tramadol/paracetamol 37.5 mg/325 mg). In studies conducted in patients with RA, the combination of tramadol/paracetamol was effective as an add-on to ongoing NSAID treatment in patients with RA-related pain. Tramadol can cause side effects, including dizziness, weakness, sleepiness, headache, nervousness, muscle tightness, and gastrointestinal symptoms (nausea, vomiting, diarrhea).3,4



Antidepressants, including tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), selective serotonin noradrenaline reuptake inhibitors (SNRIs) and norepinephrine reuptake inhibitors (NRIs), are sometimes used to help relieve RA-related pain, as well as to help with sleep problems and depression. A systematic review of studies evaluating antidepressant treatment for pain relief in RA found no evidence of an effect on pain intensity with short-term treatment (1 week) and conflicting results in terms of benefit with medium-term (1 to 6 weeks) and long-term (over 6 weeks) treatment.5



Neuromodulators, including anticonvulsants (eg. gabapentin, pregabalin), nefopam (Acupan), capsaicin, and cannabinoids are sometimes given to manage RA-related pain. A review of clinical trials of these agents found only weak evidence to support the use of oral nefopam (Acupan), topical capsaicin cream or ointment, and oral or mucosal cannabinoids as analgesics. Among these drugs, capsaicin, because of its low potential for side effects, may be considered as an add-on analgesic with an NSAID for patients with persistent pain who have failed to respond to other pain medications.6


Muscle relaxants

Muscle relaxants include drugs that reduce muscle spasm. Examples include benzodiazepines (eg. Valium [diazepam], Xanax [alprazolam]) and non-benzodiazepines medications (eg. zopiclone). A review of studies of benzodiazepine muscle relaxants for pain relief in RA failed to find evidence of benefit with these medications, alone or in combination with NSAID treatments. Similar results were found for the non-benzodiazepine agent zopiclone given over a period of two weeks. Short term (24 hours to 2 weeks) treatment with muscle relaxants was associated with significant adverse events, including drowsiness and dizziness.7


Narcotic pain relievers

Narcotic pain relievers include codeine, oxycodone, and hydrocodone. The use of the narcotic pain relievers in patients with RA is generally discouraged due to the potential for addiction with long-term use and because of the fact that they have no effect on inflammation. However, narcotic pain relievers may be useful in certain circumstances, such as in RA patients with joints that are badly damaged and who are not candidates for joint replacement surgery. Use of narcotics in these patients must be closely monitored by a rheumatologist or pain specialist.1

Written by: Jonathan Simmons | Last reviewed: September 2013.
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