rheumatology
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Transcript rheumatology
Management of
Rheumatoid arthritis,
Osteoarthritis & Gout
Dr. Eoin Casey MD FRCPI, FRCP
Background Reading
Davidson’s Principles & Practice of Medicine, 50th
Anniversary Ed, 2002
Musculoskeletal disorders, Ch 20: pg 957-1047
Clinical Assessment of the Musculoskeletal System
(handbook) Arthritis and Rheumatism Council UK
http://www.arc.org.uk/about_arth/opubs/6321/6321.pdf
General Assessment
History
Clinical examination
Functional anatomy
Physiology
Investigations
Major manifestations of
musculoskeletal disease
Symptoms & Signs
Joint pain
Stiffness
Swelling
Inflammation
Skin changes
Muscle changes
Deformity
Non-specific systemic symptoms
(weight↓; appetite↓; energy ↓; concentration ↓; mood ↓)
Osteoarthritis
Aetiology is unknown
Aims of management
Educate the patient
Control pain
Optimise function
Beneficially modify the disease process
“It is much more important to know
what sort of a patient has a
disease than what sort of a
disease a patient has.”
William Osler 1849-1919
Management of OA
Patient’s personality
Attitude
Holistic factors
- activities of daily living
- co-morbid disease
Availability, cost & logistics of evidence-based
intervention
Patient education
Randomized controlled trials have
shown that education results in
substantial improvement and
prolonged benefit
Management of OA
Exercise
- aerobic fitness
- local strengthening exercises
Weight reduction
Simple analgesia
- eg Paracetamol 1g 4-6 hrly
Non-steroidal anti-inflammatory drugs
-
(NSAIDS)
NSAIDS
>40 NSAIDS available in Ireland
Top most prescribed drugs in the world
In favour of their use are
- effectiveness
- lack of toxicity
- affordability
Variable individual tolerance and response
Non-responders to one agent may improve
with another
NSAIDS
Mechanism of Action
- ↓ prostaglandin levels
- inhibit cyclooxygenase (COX)
Cyclo-oxygenase isoforms
COX I
- housekeeping enzyme
- expressed in gastric mucosa,
platelets & kidney
COX II
- inflammatory enzyme
- expressed in various tissues
largely at sites of inflammation
The COX II controversy
Selective COX II inhibitors
Gastric side effects of NSAIDS
GIT toxicity - up to 30%
Aetiological factor in 30% gastric ulcers
10% of RA/OA patients hospitalised
annually for NSAID associated bleeding
Endoscopic evidence of ulceration in
20% of NSAID users even in absence of
symptoms
2000 deaths per annum in UK
Risk factors for NSAID gastritis
Age > 60 years
Past history of PUD
Past history of adverse effects with NSAIDS
Steroid use
High doses
Multiple NSAIDS
Specific NSAIDS eg Indomethacin, Azapropazone
↓risk - Proton pump inhibitors; Ranitidine
Cyto-protection with Mesoprostil
NSAIDS side effects
Older people are at greatest risk for
- renal
- cardiovascular
- GIT toxicity
Other treatment modalities
Nutri-pharmaceuticals
- Glucosamine
- Chondroitin Sulphate
Topical agents
Physiotherapy
Occupational therapy
Rheumatoid arthritis
Aetiology is unknown
Approach to management
Holistic approach to assessment
Education is as important as medications
NSAIDS
Corticosteroids
Disease modifying agents (slow acting)
Steroids in Rheumatoid Arthritis
Glucocorticoids in low doses <7.5mg
daily are very effective to bridge the
gap of the latent period before disease
modifying drugs work
Local intra-articular steroid injections
Disease modifying agents
Hydroxychloroquine
Salazopyrine
Penicillamine
Gold
Methotrexate
Azathioprine
Luflunomide
Cyclophosphamide, Cyclosporine
Anti TNF agents
eg Adalimumab (Humira), Etanercept (Embrel), Infliximab
Non-drug treatments
Physiotherapy
Physical treatments
Surgery
Coping strategies
Gout
Gout
Crystal deposition
Negatively bi-refringent sodium monouric
crystals in joints, bursa, tendons and kidney
Not always associated with hyperuricaemia
Stages of Gout
1. Acute Gout
2. Inter critical periods
3. Chronic tophaceous Gout
Treatment of acute attack
One of the most painful conditions
known
NSAIDS
Colchicine (main s/e diarrhoea)
Steroids
Long term management
Uricosuric agents
-
Allopurinol 100mg od increasing to 300mg od
MOA: Xanthine oxidase inhibitor
2-3 weeks after acute attack
initiation may precipitate an acute attack
Gout in Older People
Association with thiazide diuretics
Increased toxicity to Allopurinol