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Management of Rheumatoid arthritis, Osteoarthritis & Gout. Dr. Eoin Casey MD FRCPI, FRCP. Background Reading. Davidson’s Principles & Practice of Medicine, 50 th Anniversary Ed, 2002 Musculoskeletal disorders, Ch 20: pg 957-1047
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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
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 • 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