Treatment of Rheumatoid Arthritis

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic disease. Early diagnosis of RA and effective treatment with disease-modifying anti-rheumatic drugs (DMARDs) is essential to reduce joint destruction and disability. An increasing range of DMARDs is now available. Once mechanical damage has occurred, pain and joint deformity often require aids and appliances and, eventually, surgery.

Medications for rheumatoid arthritis

During the initial stages of the disease the doctor will usually prescribe medications that are known to have the fewest side effects. As the disease progresses, stronger medications may be required. Many rheumatoid arthritis medications have potentially serious side effects.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) - these are used for pain relief as well as reducing inflammation. Examples include Advil or Motrin, which are both OTC (over the counter, no prescription required). NSAIDs will not slow down the progression of the disease. When taken in high doses or over a long period they may cause complications. Side effects may include:
  • A higher risk of bruising
  • Gastric ulcers
  • Hypertension – high blood pressure
  • Kidney damage
  • Liver damage
  • Some heart problems
  • Stomach bleeding
  • Tinnitus – ringing in the ears

Cox-2 selective inhibitors, another type of NSAID, are designed to be less harmful for the stomach. However, some research has linked them to a higher risk of strokes, hypertension, heart disease and heart attacks. If the patient has a history of hypertension, high cholesterol or smokes the doctor needs to be told.

  • Corticosteroids - these are effective at reducing inflammation, pain, as well as slowing down joint damage. They are usually recommended when NSAIDs have not helped. If the patient has a single inflamed joint the doctor may inject the steroid into the joint. Effective relief is usually felt rapidly and the effect can last from weeks to months, depending on the severity of symptoms.

Examples include prednisone (Lodotra) and methylprednisolone (Medrol). Corticosteroids are generally used for acute symptoms (short term flare ups) – the dosage is then gradually reduced (tapered off). Long term use can have serious side effects. Side effects may include:

  • A higher risk of bruising
  • Cataracts
  • Diabetes
  • Round face
  • Weight gain
  • Osteoporosis
  • Glaucoma
  • Muscle weakness
  • Thinning of the skin
    • DMARDs (disease-modifying antirheumatic drugs) - this medication may slow down the progression of the disease, as well as preventing permanent damage to the joints and other tissues. The earlier the patient starts taking a DMARD the more effective it will be. It may take from four to six months before the patient starts noticing any beneficial effects. It is important to keep taking the medication even if initially it does not appear to be working. Some patients may have to try different types of DMARD before hitting on the most suitable one. This medication is usually taken indefinitely.

      Examples include leflunomide (Arava), methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin), and hydroxychloroquine (Plaquenil). Side effects may include:

    • Liver damage
    • Bone marrow suppression
    • Lung infections (severe)
      • Immunosuppressants - as rheumatoid arthritis is an auto-immune disease, suppressing the immune system helps reduce the damage to good tissue. Examples include cyclosporine (Neoral, Sandimmune, Gengraf), azathioprine (Imuran, Azasan), and cyclophosphamide (Cytoxan).

        Tumor necrosis factor-alpha inhibitors (TNF-alpha inhibitors) – the human body produces tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is an inflammatory substance. TNF-alpha inhibitors are used for the reduction of pain, morning stiffness and swollen or tender joints. Results are usually noticed within two weeks of starting treatment. Examples include (Enbrel), infliximab (Remicade) and adalimumab (Humira). Possible side effects include:

      • A higher risk of infection
      • Blood disorders
      • Congestive heart failure
      • Demyelinating diseases – erosion of the myelin sheath that normally protects nerve fibers, exposing the fibers, resulting in problems in nerve impulse conduction. This may affect several physical systems.
      • Irritation at the injection site
      • Lymphoma

Occupational therapy

An occupational therapist can help the patient learn new and effective ways of carrying out daily tasks so that stress to painful joints is minimized. For example, if the patient has sore arms and wants to push open a door, it may be better to lean into it rather than using the arms.

If the patient has painful fingers a specially devised gripping and grabbing tool may help.

Surgery

If the above-mentioned treatments have not been effective enough, the doctor may consider surgery to repair damaged joints, allowing the patient to subsequently use that joint again. Surgical intervention may also help correct deformities, or reduce pain. The following procedures may be considered:

  • Arthroplasty – total replacement of the joint. The damaged parts are surgically removed and a prosthesis (artificial joint) made of metal and plastic is inserted.
  • Tendon repair – if the tendons around the joint are loosened or ruptured, surgery may help restore them.
  • Synovectomy – this involves the removal of the joint lining, if the synovium (lining around the joint) is inflamed and causing pain.
  • Arthrodesis – if a joint replacement is not an option, the joint may be surgically fixed to promote a bone fusion; the joint is realigned or stabilized. Also called artificial ankylosis, syndesis.

Lifestyle

When a flare-up occurs the patient should rest as much as possible. Exerting very swollen and painful joints frequently results in worsening symptoms.

Generally, when flare ups are not present, the patient should exercise regularly; this will help their general health and mobility. If rheumatoid arthritis has caused muscles around the joints to become weak, exercise will help strengthen them. Exercises that do not strain the joints are best, such as swimming. A qualified physical therapist (UK: physiotherapist) can teach the patient exercises that improve mobility.

  • Applying heat or cold – tense and painful muscles may benefit from the application of heat. A 15 minute hot bath or shower may help. Some people find that using a hot pack or an electric heating pad (set at lowest setting) helps.

Pain may be dulled with cold treatment. The numbing effect of cold may also decrease muscle spasms. Patients with poor circulation or numbness should not use cold treatments. Examples of cold treatment include cold packs, soaking the affected joint in cold water, and ice massage.

Some people benefit from placing the affected joints in warm water for a few minutes, followed by cool water for one minute; repeating the cycle for about 30 minutes, ending with warm water soak.

  • Relaxation – finding ways of alleviating mental stress may help control pain. Examples include hypnosis, guided imagery, deep breathing and muscle relaxation.
  • Complementary therapies – these are commonly used by people with rheumatoid arthritis. Few studies have been carried out on how effective they are. Examples include:
  • Acupuncture
  • Chiropractic
  • Electrotherapy
  • Hydrotherapy
  • Massage
  • Nutritional supplements – for example, fish oil, glucosamine sulphate and chondriotin.
  • Osteopathy

Sources

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