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 Non-responders to one agent may

improve with anotherimprove with 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 - expressed in various tissues largely at sites of tissues 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