RHEUMATOID ARTHRITIS – MANAGEMENT

The goal of management is to:

  • reduce pain and inflammation
  • delay disease progression
  • preserve joint movement and prevent deformities

These can be achieved by a combined approach involving physical therapy, medical therapy and if required, surgery.

Physical therapy

  • Rest to the joint effectively reduces pain and relieves muscle spasm. Splints may be used to provide rest to the joint, to reduce unwanted motion, and to prevent contracture. Crutches, walkers and cane should be used to support the diseased joint.
  • Exercises for maintaining joint mobility and muscle strength without aggravating the pain and inflammation is an important part of management. This is to be individualised by the physicians for the patient.
  • Maintaining ideal weight is essential for reducing the stress on the diseased joints of lower limbs.

Medication

The goal of medical therapy in Arthritis is to relieve pain and to delay its progress. These drugs are used alone and/or in combination.

I. Non Steroid Anti-inflammatory Drugs (NSAIDs)

  • These drugs reduce pain and joint inflammation.
  • Aspirin, Ibuprofen, Naproxen, Diclofenac, Piroxicam, Meloxicam, Nimesulide, Celecoxib, Rofecoxib are the commonly used drugs.
  • Upper abdominal discomfort, nausea, vomiting are common side-effects and they can trigger asthmatic attacks.
  • Newer drugs like nimesulide, rofecoxib are stomach-friendly and less likely to precipitate asthma.

How do they work ?  They decrease the production of mediators of inflammation by inhibiting the enzyme cyclo oxygenase (COX-1 & COX-2)  thereby reducing pain and inflammation.  In the process, they also block the production of those mediators that protect the stomach wall lining. Newer drugs selectively inhibit COX-2 enzyme-sparing formation of protective mediators.

II. Corticosteroids

  • Steroids reduce inflammation and provide symptomatic relief. Considering the long term use and potential side-effects, they are used in minimum possible dose and in selected group of patients.
  • They can be used orally as well as in the form of injections in the joint (intra-articular).
  • Prednisolone is the choice for oral treatment whereas methyl prednisolone acetate or triamcinolone hexacetonide are used for intra-articular injections.
  • Its better to use oral steroids as a single morning dose. When steroids are to be discontinued, the dose should be tapered gradually over a period of time, as advised by the doctor.
  • Upper abdominal pain and discomfort, nausea, weight gain, increased risk of fungal and bacterial infection, delayed wound healing, rise in blood sugar and blood pressure, weakening of bones (osteoporosis) are the notable side-effects of steroid therapy.

How do they work ?  They inhibit the enzyme phospholipase A2 involved in production of mediators of inflammation, thereby reducing inflammation and pain. However, it also blocks the production of those mediators which are protective to stomach wall lining.

III. Disease Modifying Anti Rheumatic Drugs (DMARDs)

  • Disease modifying antirheumatic drugs (DMARDs) does not offer prompt relief but they reduce joint pain, improve joint function and delay disease progression over a period of time.
  • These drugs have considerable toxicity, so frequent monitoring is necessary during the treatment.
  • Commonly prescribed medicines are:
  • METHOTREXATE : It is taken orally on weekly basis and produces its beneficial effects in 4-6 weeks time. Stomach upset and mouth ulcers are common side effects but it may cause bone marrow depression and liver injury. Therefore, it is necessary to have complete blood count and liver function tests every 4-6 weeks while on methotrexate treatment. Incidence of side-effects can be reduced by taking folic acid. Use of alcohol and sulpha drugs should be avoided during treatment.
  • GOLD SALTS : Gold salts are used as Intramuscular injections (sodium aurothiomalate) or oral preparation (auranofin). Side-effects include itching, rashes, mouth ulcers diarrhea, kidney toxicity and bone marrow depression. So, it is necessary to have frequent complete blood counts and urine analysis while on gold salt therapy.
  • HYDROXYCHLOROQUINE : An antimalarial, the drug’s clinical benefits are usually seen after 1-3 months of treatment. This may cause nausea, loose motions, rashes, anemia and eye problems. It is advisable to get a get a complete eye check-up every 6 month while taking hydroxychloroquine.
  • SULFASALAZINE : It is an effective oral drug and can take 3-6 months in providing relief from symptoms. Nausea and vomiting are common side-effects that can be avoided by starting with a smaller dose. Rarely, it can cause anemia and liver damage. Complete blood count and liver function tests should be done every month initially and at three months interval thereafter.
  • CYCLOSPORINE : Low dose cyclosporine causes significant improvement with fewer side-effects. Side-effects include nausea, high blood pressure, kidney and liver toxicity. Complete blood count, kidney function tests and liver function tests be done frequently while taking cyclosporine.
  • AZATHIOPRINE : An immunosuppressive drug used in selected patients. Side-effects include nausea, vomiting, loose motions, bone marrow suppression and increased risk to infection. Complete blood count is necessary at regular intervals.
  • TUMOR NECROSIS FACTOR INHIBITORS : These drugs has been used recently in cases of rheumatoid arthritis.

Surgery

The aim of surgical therapy is to reduce the pain and disability in severely damaged joints. In certain cases, joint replacement may be undertaken to get a better outcome.

Monitoring the response to therapy

Response to the treatment can be assessed on the basis of:

  • Clinical parameter – Objective assessment of pain, duration of morning stiffness, number of joints involved.
  • Laboratory parameters – Erythrocyte sedimentation rate, hemoglobin.