Pain management in - patients with , ..

Rheumatoid arthritis Abstract: Rheumatoid arthritis (RA) is one of the most common inflammatory conditions in the United States affecting approximately 1 million adults. This article briefly reviews the evidence-based diagnosis ofRA, mainstays of treatment to prevent join t destruction, and pain management.

By Catherine 0. Durham, DNP, FNP; Terri Fowler, DNP, FNP; AnneMarie Donato, DNP, FNP; Whitney Smith, MSN, APRN, ANP-BC, GNP-BC; Elizabeth Jensen, DNP, FNP

heumatoid arthritis (RA) is one of the most com­ mon inflammatory pain conditions in the Unit­ ed States and the world, affecting approximately 1 million U.S. adults with a worldwide lifetime prevalence of 1%.' Women are more often affected by RA and are 2.5 times more likely to be diagnosed with the condition than men. The peak incidence occurs between ages 30 and 60 years, although RA can occur at any age.2,3 Almost 80% of all diagnosed patients report some disability, 35% require permanent work disability, and all are at risk for an over­ all reduction in life expectancy.1,2,4 Risk factors for RA include older age, gender, genetic predisposition, and smoking.1 RA is a multifactorial inflammatory condition thought to stem from an inciting inflammatory event, autoimmune response, or possible infectious etiology, although no pathogen has been identified to cause RA.1,5 Early patho­ physiologic changes in RA involve injury to the synovial microvasculature with inflammation and damage to en­ dothelial cells, leading to congestion, edema, and fibrin exudation. As the synovial membranes become thickened, granulation tissue extends into the cartilage, leading to joint destruction that involves articular cartilage, liga­ ments, tendons, and bones.1,4 This destructive process is

driven by the overproduction of proinflammatory cyto­ kines, prim arily the CD4 T cells.4 W hen CD4 T cells are activated, they stim ulate a complex inflam m atory and destructive response that leads to significant joint destruction.4 Early and effective disease modification and pain man­ agement can reduce the risk of long-term disability and improve the patient’s overall quality of life. The purpose of this article is to review the primary care management of RA with particular attention to pain management for patients with this complex condition. ■ Early detection and improved pain management

Although there is no known cure for RA, early detection can facilitate prompt treatment and, thus, can improve the chances to minimize joint destruction, obtain adequate pain relief, and achieve clinical remission. A patient will often present with vague symptoms, which makes it dif­ ficult to differentiate between RA and other disorders, such as osteoarthritis, gout, bursitis, carpel tunnel syndrome, or fibromyalgia. The American College of Rheumatology (ACR) collaborated with the European League Against Rheumatism to establish criteria for RA classification. Initially designed for research purposes, the classification

Keywords: disease-modifying antirheumatic drugs, nonsteroidal anti-inflammatory drugs, pain management, rheumatoid arthritis 3 8 The Nurse Practitioner • Vol. 40, No.

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Pain management in patients with rheumatoid arthritis

commonly prescribed biologic agents are etanercept and adalimumab. The mechanism of action differs between the types of DMARDs and is beyond the scope of this article. Multiple studies have found that early intervention (within the first year of symptoms, preferably in the first 3 to 4 months of onset) leads to improved outcomes, as much of the joint space narrowing and erosion that cause the disability associated with RA occur within the first 2 years of diagnosis.10 Studies also have found that early treatment with DMARDs produces better response rates and decreased progression of joint damage.1113 A delay in the diagnosis, referral, or initiation of treatment and D isease-m odifyin g a n tirh eu m atic cessation of DMARD use can result in drugs are the first-lin e trea tm en t fo r reduced responsiveness to DMARDs, RA according to the ACR. progression of irreversible joint dam ­ age, increase in pain, and poor functional outcomes. Patients with RA who are monitored by an expert in subcategory apply to the patient, assigning a point value to rheum atic diseases have been show n to have better the patient’s symptoms and findings. The lowest possible outcomes.14Thus, the nurse practitioner (NP) is advised to total score is zero, and the highest possible total score is 10. consult a rheum atologist prom ptly when a patient is RA is considered to be a definitive diagnosis for a patient suspected to have, or shows conclusive evidence of, RA who scores six or higher and no other likely cause of syno­ (especially with the initiation and use of DMARDs). The vitis based on lab data.6 The RA classification criteria can primary care NP may order a complete blood cell count, be applied to a patient at any point along the continuum ESR, CRP, aminotransferases, blood urea nitrogen, and of the disease and is useful for those patients with persistent creatinine level in preparation for this consultation.15 inflam m atory conditions who have previously not met The ACR offers guidelines for monitoring DMARDs criteria for a diagnosis of RA.6 once initiated.15 Adverse reactions vary based on which DMARD the patient is taking, such as a decrease in white ■ Pharmacologic pain management in RA blood cells and indications of hepatic and kidney damage.14 Although management of RA focuses on modifying dis­ It is important for NPs to familiarize themselves with the ease activity and improving physical function through specific DMARD prescribed for the patient and the risks early use of DMARDs, sym ptom control through the associated with it. treatm ent of inflammation and pain is im portant. Phar­

system can help clinicians determine who meets the crite­ ria for an RA diagnosis.6 Lab studies needed for diagnosis and classification in­ clude a C-reactive protein (CRP), erythrocyte sedimenta­ tion rate (ESR), rheumatoid factor (RF), and an anticitrullinated protein antibody (ACPA). ACPA levels can be detected long before a patient displays clinical symptoms and, thus, are a prognostic indicator for disease severity.7 Once lab studies are obtained, clinicians can apply the ACR classification criteria to determ ine which category and

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macologic m anagem ent of RA should first consist of disease-modifying agent(s), such as DMARDs and pos­ sibly corticosteroids. Treatment of inflammation and pain is the second focus of pharmacologic therapy and often achieved with NSAIDs, corticosteroids, and other adjunct therapies.1,8 Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs (DMARDs) are the first-line treatm ent for RA according to the ACR. DMARDs decrease pain and inflammation, reduce and prevent joint damage, and preserve joint function and structure.8,9 DMARDs are generally categorized as nonbiologic (conventional synthetic) and biologic (produced by recombinant DNA technology). The most commonly prescribed nonbiologic DMARDs include methotrexate, sulfasalazine, and hydroxychloroquine, while the most 40 The Nurse Practitioner

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Nonsteroidal anti-inflammatory drugs While DMARDs are considered first-line treatm ent for RA in regards to disease modification, nonsteroidal anti­ inflammatory drugs (NSAIDs) are first-line therapy for im provem ent o f inflam m ation, pain, and function. NSAIDs have anti-inflammatory and analgesic properties based on their mechanism of action and are effective in the management of chronic inflammatory pain. NSAIDs block the biosynthesis of prostaglandins that are respon­ sible for inflammation and many other processes within the body.16 The most commonly prescribed NSAIDs in­ clude: ibuprofen, naproxen, diclofenac, indom ethacin, diflunisal, m eloxicam , and celecoxib. Studies have demonstrated the benefits of NSAIDs in pain outcomes and function as well as the effectiveness of NSAIDs over ac e ta m in o p h en .17'20 However, NSAIDs do not have www.tnpj.com

Pain management in patients with rheumatoid arthritis

disease-m odifying properties and should not be used the risk of adverse events. Age should also be considered alone in the pharm acologic m anagem ent of RA, but because older adults have a higher risk of comorbidities, rather in conjunction with disease-m odifying agents, polypharmacy, and adverse reactions. NPs are advised to such as DMARDs. start with the lowest dose, frequency, and duration to help Prior to initiating NSAID therapy, providers m ust minimize risk. Consideration should be given to the class consider the potential risk and adverse events associated of NSAID when determining which NSAID to use. Cur­ with use. G astrointestinal (GI) adverse reactions are rently, all NSAIDs are nonselective except for celecoxib. common with NSAID use and range from dyspepsia to Nonselective NSAIDs, such as diflunisal, ibuprofen, naprox­ life-threatening GI bleeding.21 GI risk increases with age, en, diclofenac, indomethacin, and meloxicam, for example, comorbidities, and certain medications. A prior history inhibit both COX-1 and COX-2 and have the greatest risk o f GI bleeding, nonselective NSAID use, high-dose of GI events.21,26 NSAID use, alcohol use, tobacco use, antithrom botic Selective NSAIDs only inhibit COX-2, resulting in a drugs, and corticosteroid therapy increase the risk of lower GI risk but have a higher cardiovascular risk.21,23,26 adverse GI events.22 Cardiovascular risks are also of con­ Celecoxib (selective NSAID) should be considered in pa­ cern with NSAID therapy, including an increased risk of tients with an increased risk of GI adverse reactions.21,26 edema, hypertension, heart failure, and myocardial in­ Patients with a higher risk of cardiovascular events should farction.23 Adverse renal events should be considered in avoid selective NSAIDs (celecoxib); a nonselective NSAID NSAID therapy due to the risk of fluid retention, elec­ may be considered based on the patient’s individual car­ trolyte abnorm alities, elevated BP, and potential for diovascular risk profile.23,27'29 NSAIDs should be avoided nephrotoxicity. The U.S. FDA mandates a black box warn­ altogether in the case of high GI and cardiovascular risk.21,26 ing (for all NSAIDs) outlining the GI and cardiovascular To help negate GI adverse events, the addition of a proton risk of NSAIDs (www.fda.gov/Drugs/DrugSafety/Post pump inhibitor (PPI) such as lansoprazole, pantoprazole, marketDrugSafetylnformationforPatientsandProviders/ or rabeprazole can be prescribed in com bination with ucm l50314.htm and www.fda.gov/downloads/Advisory NSAID therapy.21,26 NSAID therapy should also be avoided Committees/CommitteesMeetingMaterials/Drugs/Arthri in patients with kidney dysfunction.21,26 tisAdvisoryCommittee/UCM386432.pdf). Drug-drug interactions are often the source of adverse Topical NSAIDs events associated with NSAID use. The combined use of Topical NSAIDs are effective pharmacologic management NSAIDs with anticoagulant and antiplatelet therapies in­ for localized, limited, superficial joint inflammation and creases the risk of bleeding through an additive effect.24 are associated with decreased systemic absorption, adverse Antihypertensive medications and diuretics in combination events, and drug-drug interactions. The topical NSAID with NSAIDs may lead to a decrease in antihypertensive available in the United States includes diclofenac available effects and an increase in nephrotoxicity risk. Prescribers as both a gel and a patch. The evidence supporting topical are advised not to treat the patient with RA with triple NSAID use with RA is lacking; however, the evidence therapy consisting of an angiotensin­ converting enzyme inhibitor or angio­ tensin II receptor blocker, diuretic, and Topical N SAIDs are effective an NSAID due to the 31% higher risk ph arm acologic m an agem en t fo r localized, of acute kidney injury with that drug combination.25In addition, combining lim ited, superficial jo in t inflam m ation. NSAIDs with systemic corticosteroids increases the risk of numerous adverse events through an additive effect, including GI ulcers, bleed­ supports the use in other chronic pain conditions, such ing, edema, and hypertension.23 as osteoarthritis with pain control at least equal to that The risks posed by NSAIDs do not negate the key role of systemic NSAIDs but with fewer adverse reactions.30 this class of medications play in RA and the importance of Due to th eir decreased systemic absorption, topical prescribing in conjunction with disease-modifying agents NSAIDs may be a consideration in certain patients who to decrease pain and improve function. When prescribing are unable to take oral NSAIDs. When prescribing, the NSAIDs, a complete history, physical, and medication list is NP should educate the patient not to use the medication essential for identifying underlying comorbidities or the on broken or irritated skin and to avoid an occlusive development of polypharmacy, both of which can increase dressing or heat. Topical NSAIDs have a maximum per

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The Nurse Practitioner • May 2015

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Pain management in patients with rheumatoid arthritis

example, NSAID therapy increases the risk of adverse GI events when combined with corticosteroids. Thus, patients should also be monitored during treatment for the develop­ ment of adverse events related to corticosteroids. The as­ Topical capsaicin sessment of BP, weight, evidence of edema or heart failure, Very limited data exist in the literature regarding the effects measurement of blood glucose and lipid levels, as well as of topical capsaicin in RA. Deal and colleagues found comprehensive eye exams should occur regularly in patients that over 80% of patients with knee osteoarthritis and taking chronic corticosteroids. Initiation of a PPI is indi­ RA noted pain reduction with topical capsaicin, and the cated to help prevent peptic ulcer disease (PUD) and GI ACR conditionally recommends its use in patients with bleeding associated with corticosteroid use, especially if osteoarthritis who have low risk.27,31 Topical capsaicin may there is concurrent NSAID or antiplatelet/anticoagulant be used as an adjunct analgesic. Joint application is recom­ use, history of PUD, GI bleeding, or advanced age. Patients mended three to four times a day, and it is important to should be included as active participants in any decision to educate patients to avoid open or irritated skin, heat, or initiate corticosteroids. NPs are advised to inform patients occlusive dressings. Patients should discontinue use if they of the risk/benefit ratio and the potential adverse events note any skin irritation. Methylsalicylate and m enthol associated with corticosteroid use.32 (Bengay) falls under the salicylate class, and there are no Adequate calcium intake, weight-bearing exercises, and current studies differentiating its use in RA. avoiding tobacco and excessive alcohol are measures that patients can implement to help reduce the risk of complica­ Corticosteroids tions. To help reduce the risk of adverse events, NPs should Similar to NSAIDs, corticosteroids are an effective phar­ prescribe the lowest dose for the shortest duration and taper macologic regimen for control of inflammation and pain corticosteroids in the event of low disease activity or in joints. Low doses of corticosteroids, such as prednisone remission.32 Starting doses of corticosteroids vary; however, (less than 10 rng/day) are effective in reducing joint inflam­ the NP should avoid undertreating the patient.34Severity of m ation and pain, and patients may experience rapid disease, comorbidities, concurrent medications, age, and im provem ent within days of starting corticosteroids.8 body mass index should be taken into consideration when A dm inistration in the m orning appears to have some deciding on a starting dose. benefit in reducing RA symptoms compared to dosing Preventive steps should be taken to reduce the risk of later in the day.32 However, corticosteroids are not recom­ long-term adverse events if long-term therapy (greater mended for routine RA pain management without signs than 3 months) is prescribed.32The corticosteroid-depen­ and sym ptom s of in fla m m a tio n .33 Like DMARDs, dent patient should consume 1,000 mg to 1,200 mg of corticosteroids have some disease-modifying effects and calcium p er day and 400 in te r n a tio n a l u n its to have been shown to slow the progression of joint damage, 800 international units of vitamin D per day. Bisphosphonates are also im­ portant to consider in the prevention O pioids are an option i f altern a tive of osteoporosis. Dual-energy X-ray therapies have been considered a n d were absorptiometry screening should oc­ eith er con train dicated or failed. cur no earlier than every 2 years in patients over the age of 65 or those younger than 65 who have a bone frac­ ture risk equal to that of a 65-year-old White woman’s risk reduce inflam m ation, and increase rem ission rates.8 for osteopenia and osteoporosis.35 Relapse is often experienced with discontinuation, even C orticosteroid therapy for at least 1 m onth also with concurrent DMARD use.8 increases the risk of adrenal insufficiency. With surgery, Systemic corticosteroids are associated with multiple patients will need perioperative therapy with adequate adverse reactions, including immunosuppression, hyper­ corticosteroid dosing to prevent adrenal insufficiency sec­ tension, dyslipidemia, diabetes mellitus, osteoporosis, ondary to the stress of the surgery. This recommendation Cushing syndrome, G1 bleeding, weight gain, fluid reten­ is im portant to note with any preoperative evaluation. tion, glaucoma, and cataracts. Providers should screen for Intra-articular corticosteroid injections are appropriate in these conditions and treat them prior to starting cortico­ the m anagem ent of RA to help decrease synovitis in steroids to help reduce the risk of adverse events. In addi­ affected joints. A provider with appropriate training and tion, current medications should also be reviewed. For

joint and total daily dosing, which should be explained to the patient.

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Pain management in patients with rheumatoid arthritis

experience should administer injections. Injection into a joint provides great response, but is not appropriate for diffuse joint involvement; moreover, the same joint should not be injected more than once in 3 m onths.8

Acetaminophen

Cochrane review of opioids in the m anagement of RA pain, Whittle and colleagues found little evidence for a beneficial effect; however, the researchers noted an in­ creased risk of adverse events.37 Opioids are an option if alternative therapies have been considered and were either contraindicated or failed. Patients should be assessed for comorbidities and concurrent med­ ication use, which may increase the risk of adverse events related to opioid use. NPs are advised to evaluate for pos­ sible abuse potential, such as prior history of substance abuse, and to consider implementing an opioid treatment

Like NSAIDs, acetam inophen inhibits prostaglandins; however, acetam inophen has weak anti-inflam m atory properties. When compared to NSAIDs, acetaminophen is often not as effectives as NSAIDs. In a survey of almost 1,800 patients, Wolfe and colleagues noted that less than 14% of the patients preferred acetamin­ ophen to NSAID therapy. However, acetam inophen has a lower adverse Yoga and tai chi have been reaction profde and is often the best found to have some benefit in pain consideration for patients at increased managem ent and functional capability. risk for adverse events related to ' NSAIDs. The ACR recognizes the effi­ cacy of NSAIDs over acetaminophen; however, the ACR recommends acetaminophen as first-line agreement to outline terms of agreement and minimize the therapy (especially in older adults) due to the lower adverse abuse potential. reaction profile.23 Weaker medications, such as tramadol, should be ini­ In a systematic literature review, Hazelwood and col­ tiated first and titrated appropriately. The old adage of leagues found little evidence for the benefit of acetamino­ “start low and go slow” is essential in the initiation and phen.36There is also a lack of strong evidence supporting the m anagem ent of opioid therapy to reduce the risk of benefit of combination acetaminophen with NSAIDs. When adverse events. Patients should be provided with education considering initiation of acetaminophen in patients with RA, regarding the adverse reactions, such as sedation, constipa­ thought must be given to the lack of evidence supporting tion, and im portance of avoiding driving or operating the benefits of acetaminophen and also to the risk of NSAID machinery while taking opioids. therapy. For therapy secondary to comorbidities, age, or concurrent medications, acetaminophen may be utilized as ■ Other adjunct therapies a first-line therapy for pain management in patients with a Other adjunct therapies that may be considered for analgesic high risk of adverse events associated with NSAID. benefit include antidepressants, anticonvulsants, muscle Providers should review the patient’s comorbidities to relaxants, and topical therapies. However, the evidence assess for potential complicating factors, such as hepatic supporting the benefits of these adjunct therapies in RA is failure, despite the safety of acetaminophen when doses are limited, and some studies show no improvement in pain within the recommended range. Providers should also offer outcomes. patient education related to the appropriate dosing of overthe-counter (OTC) acetaminophen and the avoidance of all Antidepressants other prescription and/or OTC products with acetamino­ Antidepressants are often used as adjunctive therapy in phen to avoid accidental overdose and hepatotoxicity. many chronic pain conditions to help with pain relief and

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Opioids Opioids block pain receptors throughout the body but do not provide anti-inflam m atory benefits, which is the m ainstay of RA pharmacologic therapy.8 Opioids have been a long-standing therapy in pain m anagem ent; however, adverse events continue to be a concern. In a systematic literature review, Whittle and colleagues recom­ mended utilization of weak opioids if other pharm aco­ logic therapies have failed or are contraindicated.33 In a www.tnpj.com

to treat underlying depression.38 Of the antidepressants, the serotonin norepinephrine reuptake inhibitor venlafaxine and the tricyclic antidepressant (TCA) am itripty­ line have been found to have some analgesic properties in addition to depression management; there is less evi­ dence for selective serotonin reuptake inhibitors (SSRIs).39 In regards to the specific role of antidepressants in RA, a Cochran review by Richards and colleagues found no strong evidence for the benefits of antidepressants (SSRIs) on pain outcomes in patients with RA.38That review found The Nurse Practitioner • May 2015

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Pain management in patients with rheumatoid arthritis

behavioral therapies have been shown to provide both short-term and long-term physical and psychological benefits in the pain management of the patient with RA.44 CAM includes a large group of products and practices (for example, acupuncture, meditation, herbal products, and massage). The prevalence of CAM use in the United States by patients with RA is estimated to be 28% to 90%.45 It is essential to educate patients regarding efficacy, adverse reactions, and possible drug-herb in­ teractions. It is also imperative to ad­ vise patients to report the use of CAM As w ith m ost arthritis and inflam m atory to their providers. conditions, physical activity is recommended, RA is a complex, potentially de­ such as walking, cycling, and w ater activities. bilitating condition com m on in the prim ary care setting. Managing pain and limiting disability in these patients can be complex. First-line management with DMARDs is against antidepressants, and this area needs more research. considered the mainstay for disease modification to reduce The prescribing NP will need to be aware that specific use and prevent joint damage and preserve function. These in RA is considered off-label if the patient is not diagnosed drugs can be complex to prescribe and manage and engage­ with depression. ment with a rheum atologist often yields better patient outcomes and patient satisfaction. Some patients fail to Muscle relaxants and benzodiazepines tolerate this class of medications or lack sufficient insur­ Whittle and colleagues noted a lack of evidence to support ance coverage to afford them. NPs must be knowledgeable the use o f muscle relaxants and benzodiazepines to about the risk and benefits of NSAIDs, corticosteroids, improve pain outcomes in RA patients.33 These medica­ analgesics, and adjunct therapies when prescribing these tions have a higher risk of adverse events, including seda­ treatm ents for the management of RA in this complex tion and addiction; therefore, the risks associated with patient population. © their use are of significant concern and would be im por­ tan t for the NP to consider, as prescribing would be considered off-label.33

conflicting evidence for the use of TCAs; however, more adverse reactions were noted with TCAs as compared to placebo.38 A ntidepressant adjunct therapy in patients with RA may be appropriate in patients with depression. The antidepressant may not directly decrease pain, but treat­ ment of other underlying conditions may improve func­ tion. Unfortunately, there is a lack of sufficient data for or

REFERENCES

Anticonvulsants A lack of literature regarding the use of anticonvulsants in RA limits the recommendation for use as adjunct therapy. Anticonvulsants, such as gabapentin, have been utilized off-label in several central neuropathic pain conditions, such as fibromyalgia and neuropathy. Although these may be a consideration for chronic pain management, there are few clinical trials that show analgesic effectiveness specific to RA.40 ■

N o n p h a r m a c o lo g ic an d c o m p le m e n ta ry and

a lte r n a tiv e m e d ic in e (C A M )

As w ith m ost arth ritis and inflam m atory conditions, physical activity is recommended, such as walking, cycling, and water activities to improve aerobic capacity; muscle strength training is recommended for patients with RA to improve functional ability.41'42 In addition, yoga and tai chi have been found to have some benefit in pain manage­ ment and functional capability and are considered safe for the patient with RA.41,43 Patient education and cognitive 4 4 The Nurse Practitioner • Vol. 40, No. 5

1. Wasserman AM. Diagnosis and management of rheumatoid arthritis. Am Fam Physician. 2011;84( 11):1245-1252. 2. Allaire S, Wolfe F, Niu J, LaValley MP, Zhang B, Reisine S. Current risk factors for work disability associated with rheumatoid arthritis: recent data from a US national cohort. Arthritis Rheum. 2009;61(3):321-328. 3. Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the united states. Part I. Arthritis Rheum. 2008;58(l):15-25. 4. Choy EH, Panayi GS. Cytokine pathways and joint inflammation in rheumatoid arthritis. N Engl J Med. 2001;344(12):907-916. 5. Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746): 1094-1108. 6. Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2010;69(9): 15801588. 7. Moeez S, John P, Bhatti A. Anti-citrullinated protein antibodies: role in pathogenesis of RA and potential as a diagnostic tool. Rheumatol Int. 2013; 33(7): 1669-1673. 8. American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum. 2002;46(2):328-346. 9. Nam JL, W inthrop KL, van Vollenhoven RF, et al. Current evidence for the management of rheumatoid arthritis with biological disease-modifying antirheumatic drugs: a systematic literature review informing the EULAR recommendations for the management o f RA. Ann Rheum Dis. 2010;69(6):976-986.

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Pain management in patients with rheumatoid arthritis

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12. Lard LR, Visser H, Speyer I, et al. Early versus delayed treatment in patients with recent-onset rheumatoid arthritis: Comparison of two cohorts who received different treatm ent strategies. Am J Med. 2001; 111 (6):446-451. 13. Anderson JJ, Wells G, Verhoeven AC, Felson DT. Factors predicting response to treatment in rheumatoid arthritis: the importance of disease duration. Arthritis Rheum. 2000;43(l):22-29. 14. Schur PH, Moreland LW. Monitoring drug therapy in rheumatoid arthritis. Updated n.d. 15. Singh JA, Furst DE, Bharat A, et al. 2012 update o f the 2008 american college o f rheumatology recommendations for the use of disease­ modifying antirheum atic drugs and biologic agents in the treatm ent of rheum atoid arthritis. Arthritis Care Res (Hoboken). 2012;64(5): 625-639.

31. Deal CL, Schnitzer TJ, Lipstein E, et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther. 1991; 13(3):383-395. 32. Hoes JN, Jacobs JW, Boers M, et al. EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis. 2007;66( 12): 1560-1567. 33. Whittle SL, Colebatch AN, Buchbinder R, et al. Multinational evidencebased recommendations for pain management by pharmacotherapy in inflammatory arthritis: integrating systematic literature research and expert opinion of a broad panel of rheumatologists in the 3e initiative. Rheumatology (Oxford). 2012;51 (8): 1416-1425. 34. Duru N, van der Goes MC, Jacobs JW, et al. EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis. 2013;72( 12): 1905-1913. 35. United States Preventive Services Task Force. Recommendation: Osteoporosis. 2011.

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Catherine O. Durham is an instructor, lead ANP/FNP at Medical University of South Carolina, S.C., and a nurse practitioner at U.S. Navy Reserves.

Terri Fowler is an instructor, AnneMarie Donato is an assistant professor, and Whitney Smith is an Instructor at Medical University of South Carolina, College of Nursing, Charleston, S.C.

Elizabeth Jensen is a Family Nurse Practitioner, Family Medicine Department at the U.S. Navy.

The authors have disclosed the following financial relationships: Hogeschool Leiden, MUSC, Timm, Timm 8c Timm B.V.

DOI-10.1097/01 .NPR.0000463784.36883.23

The Nurse Practitioner • May 2015

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