Management of Rheumatoid arthritis, Osteoarthritis

1
Management of Rheumatoid arthritis,
Osteoarthritis Gout

• Dr. Eoin Casey MD FRCPI, FRCP

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Background Reading

• Davidsons 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.p
  df

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General Assessment

• History
• Clinical examination
• Functional anatomy
• Physiology
• Investigations
• Major manifestations of musculoskeletal disease

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Symptoms Signs

• Joint pain
• Stiffness
• Swelling
• Inflammation
• Skin changes
• Muscle changes
• Deformity
• Non-specific systemic symptoms
• (weight? appetite? energy ? concentration
  ? mood ?)

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Osteoarthritis
Aetiology is unknown
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Aims of management

• Educate the patient
• Control pain
• Optimise function
• Beneficially modify the disease process

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• 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

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Management of OA

• Patients personality
• Attitude
• Holistic factors
• - activities of daily living
• - co-morbid disease
• Availability, cost logistics of evidence-based
  intervention

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Patient education

• Randomized controlled trials have shown that
  education results in substantial improvement and
  prolonged benefit

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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)

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NSAIDS

• gt40 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

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NSAIDS

• Mechanism of Action
• - ? prostaglandin levels
• - inhibit cyclooxygenase (COX)

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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

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The COX II controversy
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Selective COX II inhibitors
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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

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Risk factors for NSAID gastritis

• Age gt 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

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NSAIDS side effects

• Older people are at greatest risk for
• - renal
• - cardiovascular
• - GIT toxicity

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Other treatment modalities

• Nutri-pharmaceuticals
• - Glucosamine
• - Chondroitin Sulphate
• Topical agents
• Physiotherapy
• Occupational therapy

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Rheumatoid arthritis
Aetiology is unknown
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Approach to management

• Holistic approach to assessment
• Education is as important as medications
• NSAIDS
• Corticosteroids
• Disease modifying agents (slow acting)

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Steroids in Rheumatoid Arthritis

• Glucocorticoids in low doses lt7.5mg daily are
  very effective to bridge the gap of the latent
  period before disease modifying drugs work
• Local intra-articular steroid injections

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Disease modifying agents

• Hydroxychloroquine
• Salazopyrine
• Penicillamine
• Gold
• Methotrexate
• Azathioprine
• Luflunomide
• Cyclophosphamide, Cyclosporine
• Anti TNF agents
• eg Adalimumab (Humira), Etanercept (Embrel),
  Infliximab

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Non-drug treatments

• Physiotherapy
• Physical treatments
• Surgery
• Coping strategies

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Gout
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Gout

• Crystal deposition
• Negatively bi-refringent sodium monouric crystals
  in joints, bursa, tendons and kidney
• Not always associated with hyperuricaemia

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Stages of Gout

• 1. Acute Gout
• 2. Inter critical periods
• 3. Chronic tophaceous Gout

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Treatment of acute attack

• One of the most painful conditions known
• NSAIDS
• Colchicine (main s/e diarrhoea)
• Steroids

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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

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Gout in Older People

• Association with thiazide diuretics
• Increased toxicity to Allopurinol