DMARDs FOR INFLAMMATORY MSK PAIN

Recommendations are provided with the following caveats and then listed in a step-by-step process: The physician is advised to consider an individual patient’s circumstances when weighing risks and benefits of each therapy. Insufficient evidence exists on the effectiveness of DMARDs in the treatment of inflammatory musculoskeletal pain in primary SD. However, recommendations will be formulated based on expert opinion as guided by the consensus group process. The following recommendations are listed in order of the Inflammatory Musculoskeletal TRG’s preference for use in the treatment of inflammatory musculoskeletal pain in primary SD; if a therapy is insufficient in effectiveness, the physician is advised to try the next recommendation in sequence and so on.

Recommendation 1: Hydroxychloroquine (HCQ)

A first-line of treatment of inflammatory musculoskeletal pain in primary SD should be HCQ. Strength of recommendation: moderate

Recommendation 2: Methotrexate (MTX)

If HCQ is not effective in the treatment of inflammatory musculoskeletal pain in primary SD, MTX alone may be considered. Strength of recommendation: moderate or

Recommendation 3: HCQ plus MTX

If either HCQ or MTX alone is not effective in the treatment of inflammatory musculoskeletal pain in primary SD, HCQ plus MTX may be considered. Strength of recommendation: moderate

Recommendation 4a: Short-term corticosteroids

If HCQ plus MTX is not effective in the treatment of inflammatory musculoskeletal pain in primary SD, short-term (1 month or less) corticosteroids of 15 mg or less a day may be considered. Strength of recommendation: strong

Recommendation 4b: Long-term corticosteroids

Long-term (more than 1 month) 15 mg or less a day corticosteroids may be useful in the management of inflammatory musculoskeletal pain in primary SD but efforts should be made to find a steroid-sparing agent as soon as possible. Strength of recommendation: moderate The following 3 (5, 6, and 7a and 7b) recommendations are numbered in order of the TRG’s preference and experience. However, the TRG is grouping these together to allow the physician to choose any of the following and in any order based on that physician’s experience and the individual patient.

Recommendation 5: Leflunomide

If HCQ and/or MTX or short-term (1 month or less) corticosteroids are not effective in the treatment of inflammatory musculoskeletal pain in primary SD, leflunomide may be considered. Strength of recommendation: weak

Recommendation 6: Sulfasalazine

If HCQ and/or MTX, corticosteroids, or leflunomide (Arava) are not effective in the treatment of inflammatory musculoskeletal pain in primary SD, sulfasalazine may be considered. Strength of recommendation: weak

Recommendation 7a: Azathioprine

If HCQ and/or MTX, corticosteroids, leflunomide, or sulfasalazine are not effective in the treatment of inflammatory musculoskeletal pain in primary SD, azathioprine may be considered. Strength of recommendation: weak

Recommendation 7b: Potential change in order

If major organ involvement occurs in the primary SD patient, azathioprine may be a better choice than leflunomide or sulfasalazine for the treatment of all complications, including inflammatory musculoskeletal pain. Strength of recommendation: moderate

Recommendation 8: Cyclosporine

If HCQ and/or MTX, corticosteroids, leflunomide, azathioprine, or sulfasalazine are not effective in the treatment of inflammatory musculoskeletal pain in primary SD, cyclosporine may be considered. Strength of recommendation: weak