Medical treatment

nonspecific

Patient education

· remissions and exacerbations occur

· disability not inevitable

· maintain realistic lifestyle

· drugs take weeks or months to work

Rest

General

· can alleviate acute flare of polyarthritis

· reduces joint pain and swelling

· admission may be warranted

Local

· splintage can rest joint flare-up

Physical therapy

· maintain ROM

· daily movement through range

· minimise muscle wasting

· daily gentle exercises

· minimise deformity

· anatomical positioning

· eg. sleep positioning, no pillows under knees

drugs

· aims

· alleviate pain and swelling

· modify course of disease

NSAIDs

· first-line therapy

· used in almost all cases

· alleviate pain and swelling

· do not modify course of disease

· side-effects troublesome

· skin rashes

· gastric ulceration

· renal dysfunction

· care if administering with

· warfarin

· peptic ulcer disease

· advancing age

Disease-modifying drugs

· second-line therapy

· generally similar

· effective in 50-80%

· improve symptoms and signs in short and medium term

· some slowing of progress of disease

· toxicity is problem

Indications

· clinical evidence of synovitis

· inadequate response to NSAIDs

· erosive disease on x-ray

Types

Gold salts

· inhibit monocyte function

· intramuscular route

· oral less toxic but less effective

· need close monitoring

· toxicity in 30-40%

· dermatitis, mouth ulcers, pruritis (most common)

· thrombocytopaenia

· neutropaenia

· proteinuria

· screening

· FBC and urinalysis

Penicillamine

· modulates lymphocyte function

· toxicity in 50%

· similar profile to gold

Antimalarials

· chloroquine and hydroxycholoroquine

· stabilise lysosomal membranes and inhibit IL-1 function

· less life-threatening toxicity

· major side-effect is macular degeneration

· screening

· ocular examination

Sulphasalazine

· anti-folate activity

· less serious side-effects

· GIT upset

· headache

Immunosuppressants and cytotoxics

· includes

· methotrexate

· azathioprine

· cyclophosphamide

· high incidence of toxicity

· dose-related marrow suppression

· susceptibility to infection

· GI intolerance

· increased risk of malignancy

· infertility

· teratogenesis

Corticosteroids

Oral

· dramatically effective

· long-term side-effects

· osteoporosis

· hypertension

· diabetes

· indications

· refractory disease (where other treatments have failed)

· as interim therapy (while waiting for disease-modifying drugs to work)

· severe nonarticular manifestations of rheumatoid disease

· operative complications

· impaired wound healing

· increased risk of infection

· post-operative hypotension

· wound dehiscence

· cover required

· replacement of oral dose with intravenous hydrocortisone required with premedication and while unable to take oral dose

· increased dose with infection

Intra-articular

· sepsis rare with aseptic technique

· no more often than three-monthly