Rheumatological disease

9 Rheumatological disease





Drugs in rheumatology




Non-steroidal anti-inflammatory drugs (NSAIDs) (Table 9.1)


NSAIDs and paracetamol have comparable analgesic activities when given in single doses. However, with long-term use, NSAIDs also have an anti-inflammatory effect and therefore are more appropriate to use than either paracetamol or opioid analgesics in, for example, inflammatory arthritides such as rheumatoid arthritis. NSAIDs can also be used in osteoarthritis for soft-tissue problems or back pain. Paracetamol is preferred in the elderly for long-term usage.



The anti-inflammatory activity of individual NSAIDs is broadly similar but there is much variation in patient response and tolerance. Most (60%) will respond to a single NSAID, another can be tried if there is no response after 2 weeks. The analgesic effect will be achieved sooner than an anti-inflammatory effect, which may take up to 3 weeks.


NSAIDs are inhibitors of both cyclo-oxygenase 1 and 2 isoenzymes and thereby inhibit the prostaglandin pathway (Fig. 9.1). Typical agents used for rheumatological disorders are shown in Table 9.1, although there are many others.


Side-effects (Box 9.1) are common, particularly in the elderly. Indigestion and gastric erosions occur and occasionally gastrointestinal haemorrhage. The risk increases from ibuprofen (low) to, for example, diclofenac, indometacin and piroxicam (intermediate/high). Piroxicam should therefore not be used as a first-line drug and the dose should not exceed 20 mg. Bronchospasm and urticaria occur due to type 1 hypersensitivity from release of leucotrienes. Fluid retention and an increase in blood pressure can occur. Although there is a reduction in renal blood flow, acute kidney injury is rare. Avoid in pregnancy and with breast feeding, even though the amounts in the milk are small. NSAIDs should not be used if a patient is on anticoagulants, unless a proton pump inhibitor (PPI) is also given.




If the use of NSAIDs cannot be avoided in patients at high risk of gastrointestinal side-effects (those over 65 years of age, past history of peptic ulcer/bleed, concomitant steroid or warfarin use, or presence of serious comorbidity), use a non-selective NSAID combined with a PPI, e.g. omeprazole 20 mg daily. This is preferred to COX-2 inhibitors (see above). Misoprostol 200 mcg 2–3 times daily can also be used as a cytoprotective agent but causes diarrhoea.


NSAID should be used for the shortest possible time at the lowest effective dose.



Glucocorticoids



Systemic corticosteroids


These are potent anti-inflammatory agents.










Joint aspiration and injection for diagnosis and therapy (Box 9.3)



Aspiration


Aspiration should always be performed in patients with unexplained large joint effusions to obtain a diagnosis; for symptomatic relief in a patient with known arthritis; and to monitor response to treatment in an infected joint.






N.B. Aspiration and injection of joints can be painful!





Osteoarthritis (OA)






Management






Inflammatory arthritis



Rheumatoid arthritis (RA)





Management


This requires a multi-disciplinary approach based on early aggressive treatment with non-drug measures and drug therapy. The main aims are to reduce inflammation, maintain joint function, and prevent or slow the advancement of arthritis and deformity.



Drug therapy. In the first 6–12 weeks after disease onset, around 50% of patients will have negative auto-antibodies and normal X-rays. It may be difficult to differentiate RA from self-limiting post-viral arthritis during this time. One approach to treatment is to give an IM injection of methylprednisolone 120 mg (or 80 mg if < 60 kg), along with an NSAID, and review at week 12; a self-limiting polyarthropathy will have settled by this time. Persisting disease requires use of a DMARD (see below), the most common being sulfasalazine or methotrexate.

DMARDs (Table 9.2) reduce inflammation (as reflected by a reduction of joint swelling and fall in plasma acute-phase reactants), slow the development of joint erosions and prevent irreversible damage. They act slowly and achieve disease remissions in up to 70% of patients. Combinations of 2–3 drugs may be necessary. These drugs are potentially dangerous in pregnancy and contraception should be used; manufacturer’s advice should be followed.

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Rheumatological disease

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