Rheumatoid arthritis 1.pdf

NONPHARMACOLOGIC THERAPY Adequate rest, weight reduction if obese, occupational therapy, physical therapy, and use of assistive devices may improve symptoms and help maintain joint function. surgical procedures such as tenosynovectomy, tendon repair, and joint replacements. Patient education about t...

NONPHARMACOLOGIC THERAPY Adequate rest, weight reduction if obese, occupational therapy, physical therapy, and use of assistive devices may improve symptoms and help maintain joint function. surgical procedures such as tenosynovectomy, tendon repair, and joint replacements. Patient education about the disease and the benefits and limitations of drug therapy is important. PHARMACOLOGIC THERAPY General Approach A disease-modifying antirheumatic drug (DMARD) should be started within the first 3 months of symptom onset. Early use of DMARDs results → favorable outcome and can reduce mortality. First-line DMARDs include methotrexate (MTX), hydroxychloroquine, sulfasalazine, and leflunomide( MTX is often chosen initially because long-term data suggest superior outcomes compared with other DMARDs and lower cost than biologic agents). Leflunomide appears to have long- term efficacy similar to MTX. Biologic agents with disease-modifying activity include the anti-TNF agents (etanercept, infliximab, adalimumab), the IL-1 receptor antago- nist anakinra, and rituximab, which depletes peripheral B cells. Biologic agents are effective for patients who fail treatment with other DMARDs. DMARDs that are less frequently used include azathioprine, penicillamine, gold salts (including auranofin), minocycline, cyclosporine, and cyclophosphamide. These agents have either less efficacy or higher toxicity, or both. Combination therapy with two or more DMARDs may be effective when single-DMARD treatment is unsuccessful. Combinations that are particularly effective include (1) MTX plus cyclosporine, and (2) MTX plus sulfasalazine and hydroxychloroquine. Nonsteroidal antiinflammatory drugs (NSAIDs) and/or corticosteroids may be used for symptomatic relief if needed. They provide relatively rapid improvement compared with DMARDs, which may take weeks to months before benefit is seen. However, NSAIDs have no impact on disease progression, and corticosteroids have the potential for long-term complications.They possess both analgesic and antiinflammatory properties and reduce stiffness but do not slow disease progression or prevent bony erosions or joint deformity. They should seldom be used as monotherapy for RA. Methotrexate MTX inhibits cytokine production and purine biosynthesis, which may be responsible for its antiinflammatory properties. Its onset is relatively rapid (as early as 2 to 3 weeks), and 45% to 67% of patients remained on it. Toxicities are GI (stomatitis, diarrhea, nausea, vomiting), hematologic (thrombocytopenia, leukopenia), pulmonary (fibrosis, pneumonitis), and hepatic (elevated enzymes, rare cirrhosis). Concomitant folic acid may reduce some adverse effects without loss of efficacy. Liver injury tests (aspartate aminotransferase or alanine aminotransferase) should be monitored periodically, but a liver biopsy is recommended during therapy only in patients with persistently elevated hepatic enzymes. MTX is teratogenic. MTX is contraindicated in pregnant and nursing women, chronic liver disease, immunodeficiency, pleural or peritoneal effusions, leukopenia, thrombocytopenia, preexisting blood disorders, and creatinine clearance