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Arthritis - Management

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General principles. Management aims are controlling pain, minimizing disability, reducing progressive joint damage, and limiting functional and social handicaps. Most arthropathies can be managed by family physicians with a minority of cases needing specialist referral; the exception is rheumatoid arthritis, which invariably needs specialist input. General management principles for most forms of arthritis comprise patient education, lifestyle advice, treating pain with analgesics, and treating pain and inflammation with non-steroidal anti-inflammatory drugs (NSAIDs).

Nondrug treatments. Advice, education, and support that benefit patients or their care givers can be provided by medical and a variety of support staff (Puppione). Self-efficacy, maintaining general health and fitness, and avoiding obesity all need emphasis. Aids and appliances, such as walking sticks and footwear, have modest benefits, though not all elderly patients are willing or able to use them.

Exercise program that improve general fitness and muscle strength are effective. They involve lifestyle changes such as regular walking and specific muscle-strengthening program like quadriceps exercises. There is good evidence that they are effective in osteoarthritis, but evidence for rheumatoid arthritis and other arthropathies is less convincing.

Analgesics and NSAIDs. Simple analgesics like acetaminophen are effective and safe in all forms of arthritis in the elderly (American College of Rheumatology). One disadvantage is that patients are reluctant to take enough acetaminophen (e.g., 1 gram four times daily). Other analgesics,such as tramadol and dihydrocodeine, are effective in relieving arthritic pain, though constipation with dihydrocodeine and disorientation with both drugs limit their use. Compound analgesics, especially coproxamol (dextropropoxyphene and acetaminophen) are widely used, though there is limited evidence that they are better than acetaminophen.

Nonsteroid anti-inflammatory drugs (NSAIDs) are widely used to treat pain and inflammation. Short courses of NSAIDs reduce pain and joint swelling over several days or weeks, and maintain these benefits for several months. There is limited evidence for longer-term benefits. The drawback with NSAIDs is their frequent adverse reactions. The most important are gastrointestinal reactions, which range from mild indigestion to severe gastrointestinal ulcers, hemorrhages, and perforations. Other reactions include rashes and renal and liver impairment. There are variations in the prevalence of severe gastrointestinal reactions with different NSAIDs. Older drugs like indomethacin cause more problems than newer drugs like nabumetone. Recently introduced coxibs like rofecoxib and celecoxib, which selectively inhibit COX-2 enzymes, have greater gastrointestinal safety (Jackson and Hawkey). Gastrointestinal risks are also reduced by coprescribing prostaglandin analogues like misoprostol, proton-pump inhibitors like omeprazole, or H-2 antagonists like randitine.

Disease modifying antirheumatic drugs (DMARDs). These chemically diverse drugs control synovitis in rheumatoid arthritis and seronegative arthritis by modulating the immune response (Simon and Yocm). They reduce synovitis, decrease erosive damage, and improve long-term function. They are given in addition to analgesics and NSAIDs. DMARDs include methotrexate, sulfasalazine, leflunomide, azathioprine, cyclosporin, gold injections, and antimalarials (chloroquine and hydroxychloroquine). All except the antimalarials require regular monitoring for blood and liver toxicity.

DMARDs should be started soon after the diagnosis of rheumatoid arthritis has been established. Combinations of two or more DMARDs are often used, for example, triple therapy with methotrexate, sulfasalazine, and hydroxychloroquine. A recent development has been the introduction of antitumor necrosis factor (TNF) alpha immunotherapy, usually combined with methotrexate, to supplement DMARD therapy in severe disease.

Steroids. Local steroid injections benefit active inflammatory arthritis involving a single joint, irrespective of the cause, provided there is no sepsis. They can be repeated several times but should not be used excessively.

Systemic steroids, given intramuscularly or orally, are effective in acute active inflammatory arthritis, whatever the cause. They have a rapid onset of action, but their benefits may not be sustained. Their long-term use is limited by osteoporosis, thinning of the skin, increased sepsis, and other adverse reactions. It is imperative to prevent osteoporosis by giving calcium and vitamin D, with additional preventive therapy such as biphosphonates, in elderly patients on long-term systemic steroids therapy.

Other local treatments. Intra-articular artificial synovial fluid injections benefit osteoarthritis and reduce pain for up to six months. Local NSAIDs applied topically as creams or gels offer small benefits for osteoarthritis with limited adverse effects. There are similar benefits with local capsaicin, also applied topically as a cream.

Other medical treatments. Gout is treated by allopurinol, which inhibits uric acid formation. It has no value in acute gout and, because it may precipitate acute attacks, requires initial NSAID coprescription. Colchicine is an alternative approach in gout, but its efficacy is limited by diarrhea. Septic arthritis requires antibiotics; the choice depends upon the organisms involved.

Surgical treatment. The most important surgical treatment for osteoarthritis and joint failure is replacement. Many different joints can be replaced, but knees and hips are most important. Replacment reduces pain and improves function with few perioperative and postoperative complications. Most prostheses last many years. Indications for surgery include persistent pain, poor function, and anatomical evidence of joint destruction. Contra-indications include obesity, poor general health, and relative youth (as prostheses do not last indefinitely). Outcomes are better with single joint replacements, but many patients do well with multiple joint replacements. Other surgical interventions, including attempts to salvage existing joints by surface replacement, have fewer beneficial effects.

DAVID SCOTT

See also PAIN MANAGEMENT.

BIBLIOGRAPHY

American College of Rheumatology, Subcommittee on Osteoarthritis Guidelines. "Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. 2000 Update." Arthritis and Rheumatism 43, no. 9 (2000): 1905–1915.

British League Against Rheumatism. Disability and Arthritis. London: The League, 1994.

FAM, A. G. "What Is New About Crystals Other Than Monosodium Urate?" Current Opinions in Rheumatology 12, no. 3 (2000): 228–234.

KIRWAN, J. R.; CURREY, H. L.; FREEMAN, M. A.; SNOW, S.; AND YOUNG, P. J. "Overall Long-term Impact of Total Hip and Knee Joint Replacement Surgery in Patients with Osteoarthritis and Rheumatoid Arthritis." British Journal of Rheumatology 33 (1994): 357–360.

JACKSON, L. M.; AND HAWKEY, C. J. "COX-2 Selective Nonsteroidal Anti-inflammatory Drugs: Do They Really Offer Advantages?" Drugs 59, no. 6 (2000): 1207–1216.

Joint Working Group of the British Society for Rheumatology and Research Unit of the Royal College of Physicians "Guidelines for the Diagnosis, Investigation and Management of Osteorthritis of the Hip and Knee." Journal of the Royal College of Physicians (London) 27 (1993): 391–396.

PUPPIONE, A. A. "Management Strategies for Older Adults with Osteoarthritis: How to Promote and Maintain Function." Journal of the American Academy of Nurse Practitioners 167–171.

SCOTT, D. L.; SHIPLEY, M.; DAWSON, A.; EDWARDS, S.; SYMMONS, D. P.; AND WOOLF, A. D. "The Clinical Management of Rheumatoid Arthritis and Osteorthritis: Strategies for Improving Clinical Effectiveness." British Journal of Rheumatology 37, no. 5 (1998): 546–554.

SEWELL, K. L. "Rheumatoid Arthritis in Older Adults." Clinics in Geritaric Medicine 14, no. 3 (1998): 475–494.

SILMAN, A. J.; AND HOCHBERG, M. C. Epidemiology of the Rheumatic Diseases. Oxford: Oxford University Press, 1994.

SIMON, L. S.; AND YOCM, D. "New and Future Drug Therapies for Rheumatoid Arthritis." Rheumatology (Oxford) 39, supp. 1 (2000): 36–42.

VAN DOORNUM, S.; AND RYAN, P. F. "Clinical Manifestations of Gout and Their Management." Med J 172, no. 10 (2000): 493–497.

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