Editing Rheumatoid arthritis (section)

===Anti-inflammatory and analgesic agents===
[[Glucocorticoid]]s can be used in the short term and at the lowest dose possible for flare-ups and while waiting for slow-onset drugs to take effect.<ref name=ACR2015/><ref name=Lancet2016/><ref>{{cite journal | vauthors = Criswell LA, Saag KG, Sems KM, Welch V, Shea B, Wells G, Suarez-Almazor ME | title = Moderate-term, low-dose corticosteroids for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001158 | date = 1998-07-27 | volume = 2010 | pmid = 10796420 | doi = 10.1002/14651858.cd001158 | pmc = 8406983 }}</ref> Combination of glucocorticoids and conventional therapy has shown a decrease in rate of erosion of bones.<ref>{{cite journal | vauthors = Kirwan JR, Bijlsma JW, Boers M, Shea BJ | title = Effects of glucocorticoids on radiological progression in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006356 | date = January 2007 | volume = 2010 | pmid = 17253590 | pmc = 6465045 | doi = 10.1002/14651858.cd006356 }}</ref> Steroids may be injected into affected joints during the initial period of RA, prior to the use of DMARDs or oral steroids.<ref name=":3">{{cite journal | vauthors = Wallen M, Gillies D | title = Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002824 | date = January 2006 | volume = 2008 | pmid = 16437446 | doi = 10.1002/14651858.cd002824.pub2 | pmc = 8453330 }}</ref>

Non-[[Nonsteroidal anti-inflammatory drug|NSAID]] drugs to relieve pain, like [[paracetamol]] may be used to help relieve the pain symptoms; they do not change the underlying disease.<ref name=NICE2015/> The use of paracetamol may be associated with the risk of developing ulcers.<ref name=":9">{{cite journal | vauthors = Ramiro S, Radner H, van der Heijde D, van Tubergen A, Buchbinder R, Aletaha D, Landewé RB | title = Combination therapy for pain management in inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis) | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008886 | date = October 2011 | pmid = 21975788 | doi = 10.1002/14651858.cd008886.pub2 }}</ref>

[[Nonsteroidal anti-inflammatory drug|NSAIDs]] reduce both pain and stiffness in those with RA but do not affect the underlying disease and appear to have no effect on people's long term disease course and thus are no longer first line agents.<ref name=Lancet2016/><ref>{{cite journal | vauthors = Tarp S, Bartels EM, Bliddal H, Furst DE, Boers M, Danneskiold-Samsøe B, Rasmussen M, Christensen R | title = Effect of nonsteroidal antiinflammatory drugs on the C-reactive protein level in rheumatoid arthritis: a meta-analysis of randomized controlled trials | journal = Arthritis and Rheumatism | volume = 64 | issue = 11 | pages = 3511–3521 | date = November 2012 | pmid = 22833186 | doi = 10.1002/art.34644 | doi-access = free }}</ref> NSAIDs should be used with caution in those with [[gastrointestinal problem|gastrointestinal]], [[cardiovascular]], or kidney problems.<ref>{{cite journal | vauthors = Radner H, Ramiro S, Buchbinder R, Landewé RB, van der Heijde D, Aletaha D | title = Pain management for inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other spondylarthritis) and gastrointestinal or liver comorbidity | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD008951 | date = January 2012 | issue = 2 | pmid = 22258995 | doi = 10.1002/14651858.CD008951.pub2 | pmc = 8950811 | veditors = Radner H }}</ref><ref name="pmid22141388">{{cite journal | vauthors = McCormack PL | title = Celecoxib: a review of its use for symptomatic relief in the treatment of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis | journal = Drugs | volume = 71 | issue = 18 | pages = 2457–2489 | date = December 2011 | pmid = 22141388 | doi = 10.2165/11208240-000000000-00000 | s2cid = 71357689 }}</ref><ref>{{cite journal | vauthors = Marks JL, Colebatch AN, Buchbinder R, Edwards CJ | title = Pain management for rheumatoid arthritis and cardiovascular or renal comorbidity | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008952 | date = October 2011 | pmid = 21975789 | doi = 10.1002/14651858.CD008952.pub2 | veditors = Marks JL }}</ref><ref name=":9" /> Rofecoxib was withdrawn from the global market as its long-term use was associated to an increased risk of heart attacks and strokes.<ref>{{cite journal | vauthors = Garner SE, Fidan DD, Frankish RR, Judd MG, Towheed TE, Wells G, Tugwell P | title = Rofecoxib for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003685 | date = January 2005 | volume = 2010 | pmid = 15674912 | doi = 10.1002/14651858.cd003685.pub2 | pmc = 8725608 }}</ref> Use of methotrexate together with NSAIDs is safe, if adequate monitoring is done.<ref>{{cite journal | vauthors = Colebatch AN, Marks JL, Edwards CJ | title = Safety of non-steroidal anti-inflammatory drugs, including aspirin and paracetamol (acetaminophen) in people receiving methotrexate for inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, other spondyloarthritis) | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD008872 | date = November 2011 | pmid = 22071858 | doi = 10.1002/14651858.CD008872.pub2 }}</ref> [[COX-2 inhibitor]]s, such as [[celecoxib]], and NSAIDs are equally effective.<ref name=Job2008>{{cite journal | vauthors = Chen YF, Jobanputra P, Barton P, Bryan S, Fry-Smith A, Harris G, Taylor RS | title = Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation | journal = Health Technology Assessment | volume = 12 | issue = 11 | pages = 1–278, iii | date = April 2008 | pmid = 18405470 | doi = 10.3310/hta12110 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Fidahic M, Jelicic Kadic A, Radic M, Puljak L | title = Celecoxib for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012095 | date = June 2017 | issue = 6 | pmid = 28597983 | pmc = 6481589 | doi = 10.1002/14651858.CD012095.pub2 }}</ref> A 2004 Cochrane review found that people preferred NSAIDs over paracetamol.<ref name=":10">{{cite journal | vauthors = Wienecke T, Gøtzsche PC | title = Paracetamol versus nonsteroidal anti-inflammatory drugs for rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003789 | date = 2004-01-26 | volume = 2010 | pmid = 14974037 | doi = 10.1002/14651858.cd003789.pub2 | pmc = 8730319 }}</ref> However, it is yet to be clinically determined whether NSAIDs are more effective than paracetamol.<ref name=":10" />

The neuromodulator agents topical [[capsaicin]] may be reasonable to use in an attempt to reduce pain.<ref name=Ric2012/> [[Nefopam]] by mouth and [[cannabis]] are not recommended as of 2012 as the risks of use appear to be greater than the benefits.<ref name=Ric2012>{{cite journal | vauthors = Richards BL, Whittle SL, Buchbinder R | title = Neuromodulators for pain management in rheumatoid arthritis | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD008921 | date = January 2012 | issue = 1 | pmid = 22258992 | doi = 10.1002/14651858.CD008921.pub2 | pmc = 6956614 }}</ref>

Limited evidence suggests the use of weak oral opioids but the adverse effects may outweigh the benefits.<ref>{{cite journal | vauthors = Whittle SL, Richards BL, Husni E, Buchbinder R | title = Opioid therapy for treating rheumatoid arthritis pain | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD003113 | date = November 2011 | pmid = 22071805 | doi = 10.1002/14651858.cd003113.pub3 }}</ref>

Alternatively, physical therapy has been tested and shown as an effective aid in reducing pain in patients with RA. As most RA is detected early and treated aggressively, physical therapy plays more of a preventative and compensatory role, aiding in pain management alongside regular rheumatic therapy.<ref name=":13" />