Rheumatoid Arthritis Management -

Medical Treatment
Nonspecific
- Patient Education
- Remissions & exacerbations occur
- Disability not inevitable
- Maintain realistic lifestyle
- Drugs take > 1 month to work
Rest
- Can alleviate acute flare of Polyarthritis
- Reduces joint pain & swelling
- Admission may be warranted
- Splintage can rest joint flare-up
Physical Therapy
- Maintain ROM
- Daily movement through range
- Daily gentle exercises
- Minimize muscle wasting
- Minimize deformity
- Anatomical positioning
  - Eg. Sleep positioning » No pillows under knees
Medications
- Aims
  - Alleviate pain & swelling
  - Modify course of disease
- Traditional & Modern
  - Traditional is a 3 (4) tier pyramidal approach
    - NSAID 1st
    - DMARD’s 2nd
      - Gold
      - Penicillamine
      - Chloroquine
      - Sulfasalazine
    - Cytotoxics 3rd
      - Methotrexate
      - Azathioprine
      - Cyclophosphamide
    - Steroids last
  - Current trend is toward combination treatment
    - Like Chemotherapy

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
2nd-line therapy
May allow improvement or even remission of symptoms
Original rationale for usage unsure as fortuitous finding
All slow acting
Indications
- Clinical evidence of synovitis
- Inadequate response to NSAID
- Erosive disease on XR
Types
- Gold salts
- Antimalarials – Chloroquine
- D-Penicillamine
- Sulphasalazine
Activity related to
- Gold » Mononuclear cell inhibition
- D-Penicillamine » T-Lymphocyte inhibition
- Antimalarials » Stabilise lysosomal membranes & inhibit IL- I
- Sulphasalazine » Anti-folate activity
Generally similar (see* for details)
May be used sequentially & in combination
Effective in 50-80%
Improve symptoms & signs in medium term
Some slowing of progress of disease
Side effects & Toxicity is a problem » 30-40% of patients
- Rashes
- Stomatitis
- Dermatitis
- Leucopaenia
- Agranulocytosis
- Thrombocytopenia
- Nephrotic syndrome
- Glomerulonephritis
- Cholestatic jaundice
- Pulmonary
- Ocular – Macular degeneration in the antimalarials
Regular urine & blood tests required to monitor toxicity » looking at FBC & Proteinuria

*Gold Salts
- Inhibit monocyte function
- IM route (weekly)
- Need close monitoring
- Toxicity in 30-40%
- Screening with FBC & urinalysis
- Pancytopaenia & ARF
*Penicillamine
- Modulates lymphocyte function
- Toxicity in 50%
- Similar profile to Gold
*Antimalarials
- Chloroquine & Hydroxycholoroquine
- Stabilize lysosomal membranes
- Inhibit IL-1 function
- Less life-threatening toxicity
- Screen with Ocular examination for Macular degeneration
*Sulphasalazine
- Anti-Folate activity
- Less side effects

3rd-line therapy tends to be Cytotoxics
Indications
- 5-10% of RA patients with progressive disabling synovitis
Three commonest
- Methotrexate
- Azothiaprine
- Cyclophosphamide
Striking improvements seen
MTX » Pneumonitis worst complication
- 70% benefit at 4-6/52
Major side effects
- Should monitor carefully for marrow suppression & GIT toxicity
- Should not be given to child bearing aged women » Infertility & Teratogenesis
- Long term malignancy risk seen » Lymphoma with the cyclophosphamide and
- azathioprine but NOT Methotrexate
» Current Trends
- More aggressive approach recently with DMARDs
  - With the realization that NSAID are poor drugs
  - & That rheumatoid arthritis is a very significant disease
- Traditional Management results only moderate
  - With older age group dying within 10 years
  - Erosions within 10 years
- MTX very effective
  - Avara is the new replacement for MTX

Corticosteroids
4th-line therapy
Oral
Dramatically effective
Act via
- Main glucocorticoid effect is ↑ protein synthesis especially Lipocortin

Thus inhibits action of many proinflammatory products
- Prostaglandins
- Leukotrienes
- Cytokines (particularly interleukins)
Effect on lymphocyte function
- In vivo effect not clear
Indications
- Refractory disease
- As interim treatment waiting for DMARD’s to take effect
- Severe Non-Articular manifestations of RA
Long-term side effects
- Osteoporosis
- HT & DM
Operative complications
- Impaired wound healing
- Wound dehiscence
- Increased risk of infection
- Post-operative hypotension
- Cover required by replacement of oral dose
  - With IV Hydrocortisone required with
    - Pre-medication
    - While unable to take oral dose
  - Increase dose with infection
Intra-Articular steroids
- Useful for monoarticular & oligoarticular flares
- No more often than 3/12
- Sepsis rare with aseptic technique
» Current Trends
- More people die from NSAID, hence more DMARDs
- Increasing role for steroids