Pain and Stiffness resulting for inflammatory rheumatic disease
NSAID
Other analgesics in RA
Paracetamol or Codeine can also be used
DMARDs
Drugs used to influence the rheumatic disease process its self
DMARDs include:
Methotrexate Cytokine Modulators Azathioprine Cyclosporin Cyclophosphamide Leflunomide Penicillamine Gold Antimalarials ( chloroquine and hudroxychloroquine) Sulfasalazine
Which two antimalarials can be used as DMARDs?
Chloroquine and Hydroxychloroquine sulfate
Corticosteroids have a significant role in?
Rheumatoid Arthritis
Drugs which may affect the disease process in psoriatic arthritis include:
Sulfasalazine, Gold, Azathioprine, Methotrexate, Leflunomide, Cytokine modulators
For pain relief in osteoarthritis and soft tissue disorders what should be used first?
Paracetamol and may need to be taken regularly
Topical NSAID or topical capsaicin 0.025%
Should be considered particularly in knee or hand osteoarthritis
Can be substituted for or used in addition to paracetamol in OA
Oral NSAID
Further pain relief in OA
The addition of an opioid analgesic may be considered, but with a substantial risk of adverse effects
Patient on low dose aspirin
Opioid analgesic considered before a NSAID in patients taking low dose aspirin
Intra-articular corticosteroid injections
May produce temporary benefit in osteoarthritis, especially if associated with soft tissue inflammation
Non drug measures:
Weight reduction and exercise should be encouraged
Not recommended for treatment of OA
Glucosamine and Rubefacients
Hyaluronic and its derivative available for OA of the knee
But are not recommended
May reduce pain over 1-6 months
Associated with short term increase in knee inflammation
NSAIDs are only used for
Symptom control
DMARDs can affect the progression of disease
But may require 2-6 months of treatment for a full therapeutic response
Respond to DMARDs may allow
NSAID dose to be withdrawn or reduced
All patients with suspected inflammatory joint disease
Should be referred to a specialist as soon as possible to confirm diagnosis and evaluate disease activity; early initiation of DMARDs is recommended to control the signs and symptoms, and to limit joint damage
DMARDs similar in efficacy
Methotrexate
Sulfasalazine
Intramuscular gold
Penicillamine
DMARDs better tolerated
Methotrexate
Sulfasalazine
Patient with newly diagnosed active RA
A combination of DMARDS (including methotrexate and at least one other DMARD) and a short term corticosteroid
Treatment initiation to patients with newly diagnosed active RA
Within 3 months of the onset of persistent symptoms
If use of a particular DMARD is contraindicated and combination therapy is not possible
Mono therapy with a suitable DMARD should be given and the dose rapidly increased until clinically effective
Patients with established and stable RA
Cautiously reduce drug doses to the lowest that are clinically effective
When should DMARD be replaced by another
Drug does not lead to objective benefit within 6 months
Sodium aurothiomolate
Gold for active progressive RA
Given by deep IM and the area gently massaged
Test dose followed by doses at weekly intervals
Until there is definite evidence of remission
In patients who do respond
The interval between injections is then gradually increased to 4 weeks and treatment is continued for up to 5 years after complete remission
Relapse occurs
Dosage frequency immediately increased and once control obtained again should dosage frequency be decreased
When to seek alternative treatment
If no response within 2 months
Why avoid complete relapse
Since second courses of gold usually ineffective
Penicillamine
Similar action to gold
More able to continue treatment than with gold but side effects are common
Patients should be warned with penicillamine
Not to expect improvement for 6-12 weeks after treatment is initiated
When should penicillamine be discontinued
No improvement within 1 year
Beneficial effect in suppressing the inflammatory activity of RA
Sulfasalazine
Used by specialist in the management of psoriatic arthritis affecting peripheral joints
Sulfasalazine
Haematological abnormalities
Occur usually in the first 3 to 6 months of treatment with sulfasalazine and are reversible on cessation of treatment
Which antimalarial is reserved if other drugs fail
Chloroquine
Effective for mild systemic lupus erythematosus
Chloroquine and hydroxychloroquine
Not to be used for psoriatic arthritis
Better tolerated than gold and penicillamine
Retinopathy rarely occurs provided doses are not exceeded
Chloroquine and hydroxychloroquine
Drugs affecting the immune response:
Methotrexate
Leflunomide
Ciclosporin
Cyclophosphamide
By mouth once a week
Methotrexate
Mucosal and Gastrointestinal side effects with methotrexate
Folic acid given every week
Therapeutic effect starts after 4-6 weeks and improvement may continue for a further 4-6 months
Leflunomide
Leflunomide
Similar efficacy to sulfasalazine and methotrexate, may be chosen when these drugs cannot be used
Licensed for severe active rheumatoid arthritis when conventional second line therapy is inappropriate or ineffective
Ciclosporin
Some evidence that
Ciclosporin may retard the rate of erosive progression and improve symptom control in those who respond only partially to methotrexate
Cyclophosphamide
RA with severe systemic manifestation
Toxic and regular blood counts ( including platelet counts) should be carried out
Should be used under specialist supervision
Cytokine modulators
Inhibit activity of TNF-alpha
Adalimumab, certolizumab, etanercept, golimumab and infliximab
Important to distinguish drugs used
For the treatment of acute attacks of gout from those used in the long term control of the disease
The latter exacerbates and prolongs the acute manifestation of started during an attach
The management of four in adolescents requires
Specialist supervision
Acute attack of gouts
Usually treated with high doses of NSAIDs such as diclofenac and naproxen
Alternative treatment in acute attack of gout in those in which NSAIDs contraindicated
Colchicine
Aspirin
Not indicated in gout
Allopurinol, febuxostat and uricosuric
Not affective in treating an acute attack and may prolong it indefinitely if started during an acute episode
Restricted by development of toxicity in higher dose
Colchicine
Benefits of colchicine
Unlike NSAIDs can be used in HF, does not induce fluid retention
It can be given in patients receiving anticoagulant
Effective alternative in those who cannot tolerate NSAIDS or who are resistant to other treatments
Oral or parenteral corticosteroids
Long term treatment of gout
Started 1-2 weeks after the attack has settled
Allopurinol
Especially useful in renal impairment or urate stones when uricosuric drugs cannot be used
Can cause rashes
Allopurinol
Adequate urine output
With uricosuric drugs as crystallisation can occur in urine
Antagonise uricosuric drugs
Aspirin and other salicylate
Drugs that enhance neuromuscular transmission
Anticholinesterase are used as first line treatment in ocular myasthenia gravis
when anticholinesterases do not control symptoms completely
Corticosteroids are used
Frequently used to reduce dose of corticosteroids
Second line immunosuppressant such as azathioprine is used
Excessive dosage of anticholinesterases
Can impair neuromuscular transmission and precipitate cholinergic crisis by causing depolarisation block
Muscarinic side effects of anticholinesterases
Increased sweating
Increased salivary and gastric secretions
Increased gastrointestinal and uterine motility
Bradycardia
Parasympathetic effects antagonised by
Atropine sulfate
Neostigmine
Produces a therapeutic effect for up to 4 hours
