Arthralgia/myalgia

Acute Oncology Guidelines
NHS Lothian

Is the patient on chemotherapy and/or have they been receiving granulocyte colony stimulating factor (GCSF) (filgrastim/pegfilgrastim)?

SACT-induced arthralgia/myalgia1

Arthralgia is most common after taxane SACT (docetaxel or paclitaxel) and vinca alkaloids (vincristine, vinblastine, vindesine), aromatase inhibitor therapy (anastrazole, letrozole), BRAF inhibitors (vemurafenib) or after filgrastim / pegfilgrastim (GCSF) injections. It is normally a symmetrical widespread joint pain but can also be associated with muscle pain (myalgia). 

Autoimmune arthalgia/myalgia can occur as a result of immunotherapy (ipilimumab, nivolumab, pembrolizumab, atezolizumab, durvalumab). Check CK, ESR and CRP. Consult the immunotherapy-toxicities guidelines (only accessible when connected to intranet) for further information on management. 

Triage and immediate management 

See UKONS guidance for triage, immediate management and supportive guidance. Encourage rest, warmth and warm baths. Review concomitant medications. 

Medical management

Consider the severity and duration of symptoms and individual risk factors when choosing the optimal drug treatment. Commonly used options include:

Indication Drug Prescribing notes
1st line Co-codamol 30/500 1-2 tablets QDS for 3- 7 days or paracetamol 1g QDS Consider laxatives with co-codamol 
1st line - docetaxel

Gabapentin 300mg capsules OD D1, 300mg BD D2, 300mg TDS D3-10, 300mg BD D11, 300mg OD D12 then stop or 

Gabapentin 300mg capsules BD for 5 days 

Annotate on Chemocare: give first dose gabapentin on the day of docetaxel with next cycle. 

NB controlled prescription – prescribe as per CD requirements 
2nd line - no contraindications to NSAIDs Naproxen 500mg BD for 3-7 days  Caution if renal impairment, cisplatin, dyspepsia, steroids. 
3rd line Oramorph 5mg QDS for 3-5 days Only if strong and persistent pain which is not controlled with the above treatments. Only for short term use, to avoid dependence, especially if adjuvant or neoadjuvant SACT. Prescribe concurrent laxative.
  • Review the need to continue GCSF if potentially contributing. 
  • Patient should continue to check temperature and if develops a high temperature or redness in joint then phone the CTH. 
  • Annotate on Chemocare to inform future prescribers so that prophylactic meds can be prescribed where indicated. Email scheduler if SACT delay anticipated.

1. Edinburgh Cancer Centre. SACT toxicity management guideline - arthralgia (S\Tox\21)

Is the patient on immunotherapy (such as pembrolizumab, nivolumab, ipilimumab, atezolizumab, avelumab, durvalumab, cemiplimab)?

Immune-related rheumatological toxicity pathway1

Differential diagnosis: arthritis, polymyalgia rheumatica, myositis.

Abridged from: NHS Lothian Immunotherapy toxicity management guidelines v7.0. S Clive & C Barrie. Last reviewed: 22.11.2021.