Osteoarthritis & Soft Tissue Disorders - Non-pharmacological treatment
Weight reduction & Exercise
Osteoarthritis & Soft Tissue Disorders - Pharmacological treatment
1st Line: Paracetamol or Topical NSAID or Capsaicin 0.025%.
2nd Line: Add or switch to NSAID. Alternative (if Pt on Aspirin): Opioid (Not NSAID)
3rd line: Add Opioid
Other: Intra-articular corticosteroid injection (soft tissue inflammation)
Rheumatoid Arthritis (RA)
- Autoimmune disease-causing inflammation of synovial joints
- NSAIDs and other analgesics are indicated for pain and stiffness in RA.
- Conventional DMARDs include methotrexate, leflunomide, sulfasalazine and hydroxychloroquine (weak DMARD). Older DMARDS include gold, azathioprine, ciclosporin and penicillamine
- Corticosteroids are used short-term as a bridging treatment in RA when starting a new DMARD to rapidly improve symptoms; but not used long-term treatment as it’s not best practice.
- Symptom control NSAIDs, Corticosteroids (risk of osteoporosis if used long term)
RA 1st line treatment
- First Line: Methotrexate once weekly & Short-term Corticosteroid
- Alternative hydroxychloroquine (weak DMARD) in patients with mild RA or palindromic rheumatism
RA 2nd line treatment
- Second Line (inadequate relief despite dose increase): Combination therapy with another conventional DMARD - either leflunomide, sulfasalazine, or hydroxychloroquine sulfate
RA 3rd line treatment
- Third Line (no response to combo DMARDs): TNFa-inhibitor (adalimumab, certolizumab pegol, etanercept, golimumab or infliximab), biological DMARD (abatacept, sarilumab or tocilizumab) or targeted synthetic DMARD (baricitinib or tofacitinib)
RA symptom control
- short term use of NSAIDs (response to DMARD allows reduction of dose)
RA - MTX induced SE
- Folic acid once weekly on a different day
Psoriatic Arthritis
- Affects peripheral joints.
- DMARDs used: MTX or Leflunomide.
- Symptom control: NSAIDs, Corticosteroids
Systemic & Discoid (only skin) Lupus Erythematosus
- Auto-immune disease.
- Symptoms: Joint pain, butterfly rash on face, mouth ulcer etc
- Drugs used: Chloroquine / Hydroxychloroquine / Corticosteroids (not in mild cases)
Juvenile Idiopathic Arthritis
- Usually don’t require DMARDs but MTX is effective. - Alternate: Sulfasalazine (Avoid in systemic-onset JIA)
All anti-folate drugs are …
• teratogenic + cause blood dyscrasias (MTX, trimethoprim, co-trimoxazole + phenytoin)
MTX Indications:
• RA, Cancer, Severe psoriasis, Severe crohn’s disease
AVOID MTX with…
- OTC NSAIDS (risk of toxicity). MTX causes immunosuppression - have annual flu vaccine
- MTX SE: blood dyscrasias (low white + RBC, low platelets), hepatoxicity, nephrotoxicity, pulmonary toxicity, GI toxicity
MTX SE
• blood dyscrasias (low white + RBC, low platelets), hepatoxicity, nephrotoxicity, pulmonary toxicity, GI toxicity
MTX interactions:
• Increased risk of blood disorders (phenytoin, trimethoprim/co-trimoxazole, clozapine), Reduced renal excretion = MTX toxicity (NSAIDS, can be given on RX if patient monitored), Increased risk of hepatoxicity (Isotretinoin, phenothiazine antipsychotics, rifampicin, ketoconazole (hepatotoxic drugs)
Ibuprofen
Ibuprofen can be used as a painkiller, anti-inflammatory and anti-pyretic.
- When taken regularly it may be a better painkiller than paracetamol for rheumatoid arthritis, back pain, muscle pain and dental pain; it may take a week to reach full effectiveness.
- As an anti-inflammatory, it’s weaker than other NSAIDs and may take three weeks to have an effect.
- Ibuprofen can cause GI disturbances e.g. discomfort, nausea, diarrhoea and ulceration/bleeding. It should NOT be used at all in patients with existing ulceration/bleeding.
- However, it may be used in patients with risk factors for ulceration/bleeding (e.g. history of ulceration/bleeding, elderly, hepatic impairment) but are also treated with a PPI for gastro-protection.
- It should NOT be used in hepatic failure. Some people may have hypersensitivity reactions to ibuprofen presenting as rashes, swelling and bronchospasm; it can worsen asthma.
Ibuprofen can be sold OTC for short-term pain relief with a max. dose of… + on POM…
- Ibuprofen can be sold OTC for short-term pain relief with a max. dose of 400mg THREE times a day but on prescription the maximum dose is 800mg THREE times a day.
Ibuprofen + renal function
Ibuprofen may also impair renal function and increase sodium and water retention. Caution should be used in elderly with cardiac impairment, uncontrolled hypertension, diuretic therapy or peripheral arterial disease (pain in the legs). It should NOT be used in patient’s with renal impairment or heart failure.
Long-term use of ibuprofen is linked with …
increased risk of thrombotic events (myocardial infarction and cerebrovascular events). It can still be used in patients with a history of, or risk factors for, thrombotic events, but under caution. Long-term use of ibuprofen may also reversibly decrease female fertility.
Ibuprofen drug interactions
- Ibuprofen can increase the anticoagulant effect of Warfarin (increased risk of bleeding), and enhance the effects of Gliclazide;
- It can reduce excretion of Methotrexate and Lithium (increasing the risks of toxicity).
- Other drugs which may add to the risk of GI bleeding/ulceration when given with ibuprofen include SSRIs, Corticosteroids, Aspirin and Clopidogrel.
Hydroxychloroquine cautions
Take with or just after food.
- Cautions: Screen for retinopathy:
Long-term patients should receive a baseline examination within 6–12 months of treatment initiation
Annual screening is recommended in all patients who have taken hydroxychloroquine for >5 years;
Annual screening may be done before 5 years of treatment if additional retinal toxicity risk factors for exist e.g. concomitant tamoxifen therapy, high-dose (>5mg/kg/day) or eGFR <60mL/min/1.73m2 - Calculate dose based on IBW to avoid obesity toxicity
Leflunomide - Side effects + contraception
Potentially life-threatening hepatotoxicity reported usually in first 6 months. Discontinue (and institute washout procedure) or reduce dose according to liver-function abnormality; if liver-function abnormality persists after dose reduction, discontinue treatment and institute washout procedure.
- Effective contraception essential during treatment and for at least 2 years after treatment in women and at least 3 months after treatment in men. Exclude pregnancy before treatment.
Leflunomide - Monitor
- Monitor FBC (Inc. differential white cell + platelet count) + liver function before treatment + every 2 weeks for 6 months then every 8 weeks. Monitor BP
