Rheumatoid arthritis Flashcards
Investigations
ESR usu. raised according to active disease
Anaemia (normochromic and normocytic) may be present
Rheumatoid factor— +ve in ~70–80%, not specific
Anti-cyclic citrinullated peptide AB test—specific
X-ray changes
Management principles
The diagnosis generally has distressful implications
so pt and family require careful explanation, support and appropriate reassurance.
the majority of pts have little or no long-term problems.
Refer to rheumatologist for shared care
- —this referral is very important to outcome.
Specific advice
Rest and splinting: necessary where practical for any acute flare-up of arthritis.
Exercise: regular exercises esp.
- walking
- swimming
- hydrotherapy in heated pools
Referral to physiotherapists and occupational therapists: expertise in exercise supervision, physical therapy and advice regarding coping in the home and work is important.
Joint movement: each affected joint should be put daily through a full range of motion to keep it mobile and reduce stiffness.
Pharmaceutical agents
Simple analgesics e.g.
- paracetamol
- NSAIDs (use with caution)
Glucocorticoids:
- prednisolone 5–10 mg (o)/d (max 15 mg/d)
- consider: in severe disease or failure of other agents
DMARDs, e.g hydroxychloroquine
- gold compounds (IM or orally)
- D-penicillamine
- sulfasalazine
- Immunosuppressive agents, e.g.
- methotrexate (the ‘backbone’ of therapy)
- azathioprine
- cyclophosphamide
- leflunomide
- ciclosporin
- fish body oil (Omega-3)
Standard initial drug therapy RA
Methotrexate 5–10 mg (o)/wk, ↑ to max. 25 mg depending on clinical response and toxicity + folic acid 5 mg tds.
- Introduce early if indicated.
For failed therapy
consider standard triple combination therapy, e.g.
methotrexate + sulfasalazine + hydroxychloroquine
Consider (if remission not achieved with methotrexate): addition of a biological DMARD, e.g. adalimumab, entanercept, anakinra, golimumab.
