Management of Management of Rheumatoid arthritis, Rheumatoid arthritis, Osteoarthritis & Gout Osteoarthritis & Gout Dr. Eoin Casey MD FRCPI, FRCP Dr. Eoin Casey MD FRCPI, FRCP
Feb 18, 2016
Management of Management of Rheumatoid arthritis, Rheumatoid arthritis, Osteoarthritis & GoutOsteoarthritis & Gout
Dr. Eoin Casey MD FRCPI, Dr. Eoin Casey MD FRCPI, FRCPFRCP
Background ReadingBackground Reading
Davidson’s Principles & Practice of Medicine, Davidson’s Principles & Practice of Medicine, 5050thth Anniversary Ed, 2002 Anniversary Ed, 2002
Musculoskeletal disorders, Ch 20: pg 957-1047Musculoskeletal disorders, Ch 20: pg 957-1047 Clinical Assessment of the Musculoskeletal Clinical Assessment of the Musculoskeletal
System (handbook) Arthritis and Rheumatism System (handbook) Arthritis and Rheumatism Council UKCouncil UK
http://www.arc.org.uk/about_arth/opubs/6321/6321.pdfhttp://www.arc.org.uk/about_arth/opubs/6321/6321.pdf
General AssessmentGeneral Assessment HistoryHistory Clinical examinationClinical examination Functional anatomyFunctional anatomy PhysiologyPhysiology InvestigationsInvestigations Major manifestations of Major manifestations of
musculoskeletal diseasemusculoskeletal disease
Symptoms & SignsSymptoms & Signs Joint painJoint pain StiffnessStiffness SwellingSwelling InflammationInflammation Skin changesSkin changes Muscle changesMuscle changes DeformityDeformity Non-specific systemic symptomsNon-specific systemic symptoms (weight(weight↓; appetite↓; energy ↓; concentration ↓; mood ↓)↓; appetite↓; energy ↓; concentration ↓; mood ↓)
OsteoarthritisOsteoarthritis
Aetiology is unknown
Aims of managementAims of management
Educate the patientEducate the patient Control painControl pain Optimise functionOptimise function Beneficially modify the disease Beneficially modify the disease
processprocess
““It is much more important to It is much more important to know what sort of a patient know what sort of a patient has a disease than what sort has a disease than what sort of a disease a patient has.”of a disease a patient has.”
William Osler 1849-1919William Osler 1849-1919
Management of OAManagement of OA
Patient’s personalityPatient’s personality AttitudeAttitude Holistic factorsHolistic factors - activities of daily living- activities of daily living - co-morbid disease- co-morbid disease Availability, cost & logistics of evidence-Availability, cost & logistics of evidence-
based interventionbased intervention
Patient educationPatient education
Randomized controlled trials have Randomized controlled trials have shown that education results in shown that education results in substantial improvement and substantial improvement and prolonged benefitprolonged benefit
Management of OAManagement of OA ExerciseExercise - aerobic fitness- aerobic fitness - local strengthening exercises- local strengthening exercises Weight reductionWeight reduction Simple analgesiaSimple analgesia - eg Paracetamol 1g 4-6 hrly- eg Paracetamol 1g 4-6 hrly Non-steroidal anti-inflammatory drugsNon-steroidal anti-inflammatory drugs - - (NSAIDS)(NSAIDS)
NSAIDSNSAIDS >40 NSAIDS available in Ireland>40 NSAIDS available in Ireland Top most prescribed drugs in the worldTop most prescribed drugs in the world In favour of their use areIn favour of their use are - effectiveness- effectiveness - lack of toxicity- lack of toxicity - affordability- affordability Variable individual tolerance and responseVariable individual tolerance and response Non-responders to one agent may improve Non-responders to one agent may improve
with anotherwith another
NSAIDSNSAIDS
Mechanism of ActionMechanism of Action
- - ↓ prostaglandin levels↓ prostaglandin levels
- inhibit cyclooxygenase (COX)- inhibit cyclooxygenase (COX)
Cyclo-oxygenase Cyclo-oxygenase isoformsisoforms
COX I COX I - - housekeeping enzymehousekeeping enzyme - expressed in gastric - expressed in gastric
mucosa, platelets & kidneymucosa, platelets & kidney
COX II COX II - - inflammatory enzymeinflammatory enzyme - expressed in various tissues - expressed in various tissues
largely at sites of largely at sites of inflammationinflammation
The COX II controversyThe COX II controversy
Selective COX II Selective COX II inhibitorsinhibitors
Gastric side effects of Gastric side effects of NSAIDSNSAIDS
GIT toxicity - up to 30%GIT toxicity - up to 30% Aetiological factor in 30% gastric Aetiological factor in 30% gastric
ulcersulcers 10% of RA/OA patients hospitalised 10% of RA/OA patients hospitalised
annually for NSAID associated annually for NSAID associated bleedingbleeding
Endoscopic evidence of ulceration in Endoscopic evidence of ulceration in 20% of NSAID users even in absence 20% of NSAID users even in absence of symptomsof symptoms
2000 deaths per annum in UK2000 deaths per annum in UK
Risk factors for NSAID Risk factors for NSAID gastritisgastritis Age > 60 yearsAge > 60 years Past history of PUDPast history of PUD Past history of adverse effects with NSAIDSPast history of adverse effects with NSAIDS Steroid useSteroid use High dosesHigh doses Multiple NSAIDSMultiple NSAIDS Specific NSAIDS eg Indomethacin, AzapropazoneSpecific NSAIDS eg Indomethacin, Azapropazone ↓↓riskrisk - - Proton pump inhibitors; RanitidineProton pump inhibitors; Ranitidine Cyto-protection with MesoprostilCyto-protection with Mesoprostil
NSAIDS side effectsNSAIDS side effects
Older people are at greatest risk Older people are at greatest risk for for
- renal- renal - cardiovascular- cardiovascular - GIT toxicity- GIT toxicity
Other treatment Other treatment modalitiesmodalities Nutri-pharmaceuticalsNutri-pharmaceuticals - Glucosamine- Glucosamine - Chondroitin Sulphate- Chondroitin Sulphate Topical agentsTopical agents PhysiotherapyPhysiotherapy Occupational therapyOccupational therapy
Rheumatoid arthritisRheumatoid arthritis
Aetiology is unknown
Approach to Approach to managementmanagement Holistic approach to assessmentHolistic approach to assessment Education is as important as Education is as important as
medicationsmedications NSAIDS NSAIDS CorticosteroidsCorticosteroids Disease modifying agents (slow acting)Disease modifying agents (slow acting)
Steroids in Rheumatoid Steroids in Rheumatoid ArthritisArthritis
Glucocorticoids in low doses <7.5mg Glucocorticoids in low doses <7.5mg daily are very effective to bridge the daily are very effective to bridge the gap of the latent period before gap of the latent period before disease modifying drugs workdisease modifying drugs work
Local intra-articular steroid injectionsLocal intra-articular steroid injections
Disease modifying Disease modifying agentsagents HydroxychloroquineHydroxychloroquine SalazopyrineSalazopyrine PenicillaminePenicillamine GoldGold MethotrexateMethotrexate AzathioprineAzathioprine LuflunomideLuflunomide Cyclophosphamide, CyclosporineCyclophosphamide, Cyclosporine Anti TNF agents Anti TNF agents eg Adalimumab (Humira), Etanercept (Embrel), Infliximabeg Adalimumab (Humira), Etanercept (Embrel), Infliximab
Non-drug treatmentsNon-drug treatments
PhysiotherapyPhysiotherapy Physical treatmentsPhysical treatments SurgerySurgery Coping strategiesCoping strategies
GoutGout
GoutGout
Crystal depositionCrystal deposition Negatively bi-refringent sodium monouric Negatively bi-refringent sodium monouric
crystals in joints, bursa, tendons and crystals in joints, bursa, tendons and kidneykidney
Not always associated with hyperuricaemia Not always associated with hyperuricaemia
Stages of GoutStages of Gout
1. Acute Gout1. Acute Gout 2. Inter critical periods2. Inter critical periods 3. Chronic tophaceous Gout3. Chronic tophaceous Gout
Treatment of acute Treatment of acute attackattack One of the most painful One of the most painful
conditions knownconditions known NSAIDSNSAIDS Colchicine (main s/e diarrhoea)Colchicine (main s/e diarrhoea) SteroidsSteroids
Long term Long term managementmanagement Uricosuric agents Uricosuric agents
- Allopurinol 100mg od increasing to 300mg - Allopurinol 100mg od increasing to 300mg odod
- MOA: Xanthine oxidase inhibitor- MOA: Xanthine oxidase inhibitor - 2-3 weeks after acute attack- 2-3 weeks after acute attack - initiation may precipitate an acute attack- initiation may precipitate an acute attack
Gout in Older PeopleGout in Older People
Association with thiazide diureticsAssociation with thiazide diuretics Increased toxicity to AllopurinolIncreased toxicity to Allopurinol