PEBC MCQ study guide: Rheumatology, Pain Management & Palliative Care

Providing Care – Clinical Care

Osteoarthritis, rheumatoid arthritis, gout, chronic pain, and palliative symptom control.

Osteoarthritis

Acetaminophen is first-line for mild OA pain given its favourable safety profile, though evidence for its efficacy in OA specifically is modest. Topical NSAIDs are preferred over oral NSAIDs for localized OA (e.g., knee, hand) due to substantially lower systemic exposure/GI-renal-CV risk. Oral NSAIDs are used when topical/acetaminophen are inadequate, at the lowest effective dose and shortest duration, with GI protection (PPI co-therapy) considered in higher-risk patients. Intra-articular corticosteroid injections provide short-term relief for flares but are limited in frequency due to cartilage effects with repeated use.

Rheumatoid Arthritis

Methotrexate is the anchor first-line disease-modifying antirheumatic drug (DMARD) for RA, started promptly after diagnosis (early aggressive treatment improves long-term outcomes — "window of opportunity" concept). Folic acid supplementation reduces methotrexate GI/hepatic/hematologic toxicity without reducing efficacy and should always accompany methotrexate therapy.

Biologic DMARDs (anti-TNF agents: etanercept, adalimumab, infliximab; and other classes: rituximab, tocilizumab, JAK inhibitors like tofacitinib) are added when methotrexate/conventional DMARDs provide inadequate response. Biologics carry increased infection risk (including TB reactivation — screening required before starting) and are typically held around surgery and live vaccinations avoided during therapy.

NSAIDs and corticosteroids provide symptomatic relief but do NOT alter disease progression — they are adjuncts to, never substitutes for, DMARD therapy.

Gout

Acute gout flare: NSAIDs, colchicine, or corticosteroids (oral or intra-articular) are all first-line options, chosen by patient comorbidities (e.g., avoid NSAIDs in renal impairment, avoid colchicine at high doses/renal impairment for toxicity risk).

Urate-lowering therapy (allopurinol first-line, febuxostat as an alternative) is NOT started during an acute flare (can prolong/worsen it) — it's initiated after the flare resolves, with flare prophylaxis (low-dose colchicine or NSAID) continued for several months while urate-lowering therapy is up-titrated to a target serum urate (<360 µmol/L, or <300 µmol/L with tophi). Allopurinol requires renal dose adjustment and carries a rare but serious hypersensitivity syndrome risk, higher in certain HLA-B*5801-positive populations (notably some Southeast Asian ancestries) — genetic screening is considered in higher-risk groups before starting.

Chronic Non-Cancer Pain & Opioids

The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain remains the operative Canadian framework: non-opioid and non-pharmacologic therapy is recommended first-line; opioids are reserved for patients with inadequate response, started at the lowest effective dose, with a strong recommendation to stay below 90 mg morphine-equivalent dose/day (caution advised above 50 MED/day) given the steep rise in overdose risk at higher doses.

Opioid initiation should include a documented treatment agreement, regular reassessment of benefit vs. harm, and consideration of naloxone co-prescribing for higher-risk patients (higher MED, concurrent benzodiazepine use, prior overdose). Concurrent benzodiazepine + opioid use significantly increases respiratory depression/overdose risk and should be avoided or minimized wherever possible.

Palliative Symptom Management

Pain: opioids are titrated based on response without an arbitrary maximum dose ceiling in the palliative/end-of-life context (unlike chronic non-cancer pain) — the goal is effective symptom control. Breakthrough dosing is typically 10–15% of the total daily opioid dose, given as needed.

Dyspnea: low-dose opioids reduce the sensation of breathlessness independent of any effect on oxygenation. Nausea: agent choice is guided by presumed mechanism (metoclopramide for gastroparesis/delayed gastric emptying, haloperidol or ondansetron for chemically-mediated nausea, dimenhydrinate for vestibular causes).

Bowel regimen: essentially all patients on scheduled opioids need a prophylactic stimulant laxative (senna) — opioid-induced constipation does not resolve with tolerance the way sedation/nausea often do, so bowel prophylaxis is continued for the duration of opioid therapy, not just initially.

High-yield points

Methotrexate is anchor DMARD therapy for RA — always co-prescribe folic acid; NSAIDs/steroids treat symptoms only, never disease progression.
Urate-lowering therapy (allopurinol) is NEVER started during an acute gout flare — start after resolution, with flare prophylaxis overlapping.
2017 Canadian opioid guideline: caution above 50 MED/day, strong recommendation to stay below 90 MED/day for chronic non-cancer pain.
Opioid + benzodiazepine combination significantly raises overdose risk — a major counseling/safety flag.
Every patient on scheduled opioids needs a prophylactic stimulant laxative — opioid constipation does not resolve with tolerance.

Guideline references

2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain
Canadian Rheumatology Association Recommendations
Canadian Hospice Palliative Care Association