Download rheumatology

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