RΗEUMATOLOGY CENTER limassol

Basic Program (Nonpharmacologic Management)

The primary objectives in treating rheumatoid arthritis are reduction of inflammation and pain, preservation of function, and prevention of deformity. Success requires early, effective pharmacologic intervention and ongoing input by physical and occupational therapists. Disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis of rheumatoid disease is certain and then adjusted with the aim of suppressing disease activity. In advanced disease, surgical intervention may help improve function of damaged joints and to relieve pain.

Education and emotional factors

The clinician should explain the disease, describe its fluctuations, and involve the patient and family in decisions about therapy.

Physical and occupational therapies

Physical and occupational therapists understand nonpharmacologic treatments of arthritis (described below) and can effectively teach them. The therapist can develop a program the patient can follow at home, with only periodic monitoring.

Systemic rest

The amount of systemic rest required depends on the presence and severity of inflammation. With mild inflammation, 2 hours of rest each day may suffice. In general, rest should be continued until significant improvement is sustained for at least 2 weeks; thereafter, the program may be liberalized. However, the increase of physical activity must proceed gradually and with appropriate support for any involved weight-bearing joints.

Articular rest

Decrease of articular inflammation may be expedited by joint rest. Relaxation and stretching of the hip and knee muscles, to prevent flexion contractures, can be accomplished by having the patient lie in the prone position for 15 minutes several times daily. Sitting in a flexed position for prolonged periods is a poor form of joint rest. Appropriate adjustable supports provide rest for inflamed weight-bearing joints, relieve spasm, and may reduce deformities, soft tissue contracture, or instability of the ligaments. The supports must be removable to permit daily range of motion and exercise of the affected extremities (see below).

Exercise

Exercises are designed to preserve joint motion, muscular strength, and endurance. Initially, for inflammatory disease, passive range of motion and isometric exercises (such as straight leg raising) are best tolerated. In hydrotherapy, the buoyancy of water permits maximum isotonic and isometric exercise with no more stress on joints than active range of motion exercises. As tolerance for exercise increases and the activity of the disease subsides, progressive resistance exercises may be introduced. Patients should follow the general rule of eliminating any exercise that produces increased pain 1 hour after the exercise has ended.

Heat and cold

These are used primarily for their muscle-relaxing and analgesic effects. Radiant or moist heat is generally most satisfactory. Exercise may be better performed after exposure to heat. Some patients derive more relief of joint pain from local application of cold.

Assistive devices

Patients with significant hip or knee arthritis may benefit from having an elevated toilet, a gripping bar, or a cane. Patients hold the cane in the hand opposite to the affected knee or hip, thus leaning away from the affected joint. Crutches or walkers may be needed for patients with more extensive disease.

Splints

Splints may provide joint rest, reduce pain, and prevent contracture, but their use should be guided by certain principles.

a. Night splints of the hands or wrists (or both) should maintain the extremity in the position of optimum function. The elbow and shoulder lose motion so rapidly that other local measures and corticosteroid injections are usually preferable to splints.

b. The best "splint" for the hip is prone-lying for several hours a day on a firm bed. For the knee, prone-lying may suffice, but splints in maximum tolerated extension are frequently needed. Ankle splints are of the simple right-angle type.

c. Splints should be applied for the shortest period needed, should be made of lightweight materials for comfort, and should be easily removable for range-of-motion exercises once or twice daily to prevent loss of motion.

d. Corrective splints, such as those for overcoming knee flexion contractures, should be used under the guidance of a clinician familiar with their proper use.

Note: Avoidance of prolonged sitting or knee pillows may decrease the need for splints.

Weight loss

For overweight patients, achieving ideal body weight will reduce the wear and tear placed on arthritic joints of the lower extremities.

Nonsteroidal Anti-inflammatory Drugs

NSAIDs provide some symptomatic relief in rheumatoid arthritis but do not prevent erosions or alter disease progression. They are not appropriate for monotherapy and should only be used in conjunction with DMARDs. A large number of NSAIDs are available; all appear equivalent in terms of efficacy (see Table 5–3).

NSAIDs work in arthritis by the same mechanism that causes side effects: inhibition of COX, the enzyme that converts arachidonic acid to prostaglandins. Although prostaglandins play important roles in promoting inflammation and pain, they also help maintain homeostasis in several organs—especially the stomach, where prostaglandin E serves as a local hormone responsible for gastric mucosal cytoprotection. The discovery that COX exists in two isomers—COX-1 (which is expressed continuously in many cells and is responsible for the salutary effects of prostaglandins) and COX-2 (which is induced by cytokines and expressed in inflammatory tissues)—was initially of little practical consequence since all traditional NSAIDs inhibit both isomers.

Celecoxib, a selective COX-2 inhibitor, is FDA-approved for the treatment of osteoarthritis and rheumatoid arthritis. Compared with traditional NSAIDs, COX-2 inhibitors are as effective for treating rheumatoid arthritis but less likely in some circumstances to cause upper gastrointestinal tract adverse events (eg, obstruction, perforation, hemorrhage, or ulceration). Long-term use of COX-2 inhibitors, particularly in the absence of concomitant aspirin use, has been associated with an increased risk of cardiovascular events, leading to the removal of some COX-2 inhibitors from the US market and intense scrutiny of all drugs in that class.

Corticosteroids

Low-dose corticosteroids (eg, oral prednisone 5–10 mg daily) produce a prompt anti-inflammatory effect in rheumatoid arthritis and slow the rate of bony destruction. However, their multiple side effects limit their long-term use.

Methotrexate

Methotrexate is usually the initial synthetic DMARD of choice for patients with rheumatoid arthritis. It is generally well tolerated and often produces a beneficial effect in 2–6 weeks

Other symptoms

Palmar erythema is common. Occasionally, a small vessel vasculitis develops and manifests as tiny hemorrhagic infarcts in the nail folds or finger pulps. Although necrotizing arteritis is well reported, it is rare. Pericarditis and pleural disease, when present, are usually silent clinically. Additional extra-articular manifestations of rheumatoid arthritis include pulmonary fibrosis, mononuclear cell infiltration of skeletal muscle and perineurium, and hyperplasia of lymph nodes. A small subset of patients with rheumatoid arthritis have Felty's syndrome, the occurrence of splenomegaly and neutropenia, usually in the setting of severe, destructive arthritis. Felty's syndrome must be distinguished from the large granular lymphocyte syndrome, with which it shares many features.

Aortitis is a rare late complication that can result in aortic regurgitation or rupture and is usually associated with evidence of rheumatoid vasculitis elsewhere in the body.

Laboratory Findings

Anti-CCP antibodies and rheumatoid factor, an IgM antibody directed against the Fc fragment of IgG, are present in 70–80% of patients with established rheumatoid arthritis but have sensitivities of only 50% in early disease. Anti-CCP antibodies are the most specific blood test for rheumatoid arthritis (specificity ~95%). Rheumatoid factor can occur in other autoimmune disease and in chronic infections, including hepatitis C, syphilis, subacute bacterial endocarditis, and tuberculosis. The prevalence of rheumatoid factor positivity also rises with age in healthy individuals. Approximately 20% of rheumatoid patients have antinuclear antibodies.

The ESR and levels of C-reactive protein are typically elevated in proportion to disease activity. A moderate hypochromic normocytic anemia is common. The white cell count is normal or slightly elevated, but leukopenia may occur, often in the presence of splenomegaly (eg, Felty's syndrome). The platelet count is often elevated, roughly in proportion to the severity of overall joint inflammation. Initial joint fluid examination confirms the inflammatory nature of the arthritis. (See Table 20–2.) Arthrocentesis is needed to diagnose superimposed septic arthritis which is a common complication of rheumatoid arthritis and should be considered whenever a patient with rheumatoid arthritis has one joint inflamed out of proportion to the rest.

Imaging

Of all the laboratory tests, radiographic changes are the most specific for rheumatoid arthritis. Radiographs obtained during the first 6 months of symptoms, however, are usually normal. The earliest changes occur in the wrists or feet and consist of soft tissue swelling and juxta-articular demineralization. Later, diagnostic changes of uniform joint space narrowing and erosions develop (see x-ray). The erosions are often first evident at the ulnar styloid and at the juxta-articular margin, where the bony surface is not protected by cartilage. Diagnostic changes also occur in the cervical spine, with C1–2 subluxation, but these changes usually take many years to develop. Although both MRI and ultrasonography are more sensitive than radiographs in detecting bony and soft tissue changes in rheumatoid arthritis, their value in early diagnosis relative to that of plain radiographs has not been established.