Maureen E. Knell, Pharm.D., BCPS

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Rheumatoid Arthritis (RA) and Osteoarthritis
(OA)

• Maureen E. Knell, Pharm.D., BCPS
• Clinical Assistant Professor
• Saint Lukes Multispecialty Clinic

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OA and RA

• Differences between OA and RA?
• What drug therapies are indicated/effective in
  both diseases?
• What drug therapies are indicated/effective for
  OA, but not RA?
• What drug therapies are indicated/effective for
  RA, but not OA?

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Treatment Approaches to Chronic Pain - Nociceptive

• Inflammatory pain WHO Analgesic Ladder
• Acetaminophen (?)
• Depends on underlying condition
• NSAIDs, non-acetylated salicylates, COX II
  inhibitors
• Opioids/Tramadol
• Adjuvants
• TCAs (pain and sleep)
• Muscle relaxants (short-term)
• Other antidepressants (pain and depression)
• Topical products (capsaicin)
• Immunomodulators (DMARDs in RA)
• Non-RX

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Rheumatoid Arthritis
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RA Considerations

• ACR Criteria for diagnosis
• Systemic, inflammatory disease
• Laboratory testing/monitoring
• RF /- (x 1 only diagnostic, not monitoring)
• ESR/sed rate or C reactive protein
• Anemia of chronic disease
• Long-term and/or high dose use of drug therapy
  (NSAIDs, DMARDs, steroids) increases risk of
  toxicities
• Increases need for long-term monitoring

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Case 2
HPI JF is a 56yobf CC fatigue / worsening pain
stiffness in her fingers, wrists and hand PMH
similar sx 1 1/2 years ago. Took Motrin IB prn
for pain relief. PSH Hysterectomy, 1993 SH see
syllabus Taking Motrin IB (averaging 8
tablets/day), but reports inadequate pain relief
over the past month. Meds Premarin 0.625 mg qd,
multivitamin qd, Motrin PE see syllabus
Allergies - PCN - rash, tongue swelling as a
child. Ht 5'7" wt-158 lbs
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Case 2

• ADDITIONAL DATA -
• PROBLEMS -

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Case 2 - RA GOALS

• Minimize pain - 1-2 weeks decrease inflammation
  (swelling/stiffness) 2-4 weeks
• Slow / prevent RA dz progression within 3 months
  and lifelong
• Minimize / decrease disability and maintain ADLs
  - life-long (also depends on DMARD onset of
  action)
• Other Chronic Pain Goals (Syndrome/QOL)
• Continue HRT (hysterectomy) for now - address
  more aggressive osteoporosis prevention
  (particularly if on steroids)
• Educate pt about dz and tx today
• Maintain body weight long-term to minimize stress
  on joints

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Case 2 - Treatment Plan?

• Algorithm (Figure 89-4, page 1676, Dipiro)
• One caveat some Rheumatologic experts would use
  MTX 1st line for mild to moderate disease
• Three components
• Non-pharmacological
• Symptomatic relief
• Disease modifying (mild vs. severe)
• Address other identified problems
• Osteoporosis risk
• Weight Maintenance

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Case 2 - Pt Education and Monitoring

• PT. EDUCATION
• dz information
• education of treatment recommendations (Rx and
  Non-Rx)
• MONITORING
• efficacy
• complications/worsening condition
• common /severe adverse drug effects

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Current Issues in RA

• DMARDs vs. Biologics in RA
• Combination DMARDs/biologics in RA
• especially early RA
• Special populations
• Disease self-management (for OA too)

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Case 3
JF (from Case 2) returns to clinic 5 months after
her first visit. Despite good compliance with her
drug regimen and exercise program, JF presents
with more extensive joint involvement including
mild but noticeable swan neck deformity in
fingers, and ankle pain and swelling. She reports
pain and stiffness are worse than her initial
presentation and "last all day". She says she is
reluctantly considering taking early retirement
due to her condition. She expresses she is
depressed and frustrated and asks if there
anything else she can try? PMH / PSH / Current
meds - same as prior visit Ht 5'7" Wt 132 lbs.
COMPLETE TREATMENT PLAN
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JRA

• subtypes of JRA
• many complain of little or no pain
• limit or modify movements
• stiffness common

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Treatment of JRA

• NSAIDs - ASA (traditional 1st line)
• DMARDs
• MTX
• SSZ
• biologics
• Systemic corticosteroid (last line) - qod
• IAC

• HCQ
• IM Gold (po Gold)
• DP

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Osteoarthritis (OA)(do not interchange with OP -
osteoporosis)
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Special Considerations for the OA patient

• most common joint disorder
• affects 16 million people in the U.S.
• 12 of adults in the U.S.
• older population (dosing/toxicity issues)
• often self-diagnosed
• often initially self-managed with OTC products
• (so ask the patient about products of prior use)

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Case 1

• GS 77 yowm enters pharmacy
• CC arthritis - R shoulder, R knee and both hands
• Asks about OTC products
• PMH - HTN (BP 130/80), needs to lose 20 lbs

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Case 1

• ADDITIONAL DATA - questions or issues to discuss
  with GS
• PROBLEMS

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Case 1 - OA GOALS

• 1.a. Minimize OA symptoms (pain/stiffness)
  (within 1-2 weeks, 2-4 weeks if inflammation is
  more severe)
• b. Maintain/improve ADLs/mobility and
  prevent/delay progression of OA to minimize
  disabilities long-term
• c. address any underlying emotional, social
  issues, specific QOL issues. Include appropriate
  timeframes
• 2. Control HTN
• 3. Encourage weight loss 10 reduction in 6
  months (1-2 lbs/wk) then additional wt loss as
  indicated with weight control/ maintenance
  lifelong
• 4. Educate pt about dz and tx today

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Case 1 - OA Treatment Plan?

• Mild OA
• APAP (prn /scheduled)
• Other 1st line- topical capsaicin (limited joint
  involvement)
• 2nd line - OTC/RX NSAIDs (prn / scheduled)
• Moderate OA
• RX NSAIDs (scheduled)
• Severe OA
• Possible combinations -
• RX NSAIDs Intra-articular injections
• RX NSAIDs Opioids/Tramadol
• Treatment of other problems
• HTN
• Weight loss program

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Current Issues in OA

• Effectiveness of APAP in OA
• Lower toxicity
• NSAIDs and COX-2 Inhibitors
• Adequate trials/appropriate doses
• ADRs, Drug/Disease state interactions
• Use of glucosamine and other natural products
• Disease modifying potential with glucosamine?
• Other therapy options
• Topical production
• Intra-articular injections
• Viscosupplementation
• Corticosteroids
• Special populations

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Non-pharmacologic Therapy Always First Line in
Arthritis

• exercise
• rest
• heat and cold treatments
• weight loss / weight control programs
• joint protection

• braces and adaptive devices
• education
• arthritis support groups (Arthritis Foundation)
• relaxation / coping techniques

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Case 1- Pt Education and Monitoring

• PT. EDUCATION
• dz information
• education of treatment recommendations (Rx and
  Non-Rx)
• MONITORING
• efficacy
• complications/worsening condition
• common /severe adverse drug effects

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Take Home Points

• Gaining knowledge and insight into pain
  management will aid in better pain management of
  your patients in all disease states that involve
  pain
• Multi-therapy approach (non-RX, analgesics,
  anti-inflammatory agents opioids, adjuvants) is
  often indicated
• Know which drugs most effective for which types
  of pain

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Take Home Points

• OA - multiple therapy options (usually start with
  monotherapy then add), but no conclusively proven
  option to decrease disease progression
• RA - growing evidence to support combination
  DMARD therapy, especially in early disease
• Requires diligent monitoring for toxicities