PART-2-RHEUMATOID ARTHRITIS

RHEUMATOID-DIAGNOSIS AND THERAPY

 RA

Generally it is very difficult to diagnose RA at the early stages as it is mostly asymptomatic in the beginning.

RA diagnoses are based on their symptoms and laboratory findings as follows.

Diagnoses

 

1. Joint symptoms such as swelling, abnormal fluid collections in articular cavities, synovial thickening, and edema with pain on motion, indicates the presence of RA.

2. Subcutaneous nodules mostly occur in the sites exposed to external pressure such as elbow, shoulder, and wrist but also in other organs indicates the presence of RA. These nodules are rubbery, round, and firm masses can be identified with fingers.

3. A deeper diagnosis by X-radiation can indicate the presence of asymptomatic early RA by the presence of mild painless soft tissue swellings.

4. A blood test can show the presence of RA factors, heterogeneous antibodies present in most RA patients. 

5.ESR test may be high which indicates the presence of early RA.

6. The presence of normochromic, normocytic anemia may indicate the presence of RA.

Treatments

 

The treatments involve two methodological approaches such as Mechanical and Pharmacological.

Mechanical Methods

The patient should be trained with proper balanced daily exercises and rests as follows:-

1. In the beginning start with how to keep the joints in rest.

2. Start the exercise by step by step movements of the joints without straining them to strengthen the muscles.

3.when return to sleep train how to keep the joints by aligning them by the use of specially designed lightweight splints.

4. Complete immobilization should be avoided.

5. When the above methods fail a mild surgery to improve the functions and movements of hands and knees are advised.

Pharmacological Methods 

Analgesics and anti-inflammatory drugs such as aspirin and NSAIDs are beneficial. Paracetamol has not been used as it is not having any anti-inflammatory effects.

Anti-inflammatory drugs at their therapeutic dosage are riskier and the risk factors override the required therapeutic response.

Aspirin

We have already dealt with this drug in detail in another post (9-12-2015) in the same blog under the heading "Paracetamol, Aspirin and other NSAIDs".Please download it.

A piece of additional information is aspirin is the first-line drug to treat rheumatism. Aspirin is used in higher dosage to treat inflammation and it is more economical. But its risk factor overrides its benefits.

Mechanism

Aspirin is acting similar to other NSAIDs but to a lesser extent it is preventing the synthesis and release of prostaglandin.

Dose

4 to 6 gms daily

For side effects please refer to the post "Paracetamol, Aspirin, and Other NSAIDs" in this blog.

Other NSAIDs:-

They are ibuprofen, naproxen, sulindac, and piroxicam. Please refer to the following table.

Actions are similar to aspirin by inhibiting cyclooxygenase 1 and 2 and thereby inhibiting the synthesis and release of prostaglandin.

NSAIDs have the advantage over aspirin by producing the required effects in a much lower dosage than aspirin but are more expensive.

Special Precautions

1. They should be avoided in asthmatic patients as they can elevate bronchospasm. Aspirin is suitable for them.

2. Unlike aspirin NSAIDs reversibly affect the platelet function, hence safer than aspirin but still should be cautious in using them to those who have gastric bleeding.

Misoprostol is used to treat gastric hemorrhages caused by NSAIDs.(Misoprostol dosage:100 to 200 mcg four times daily along with NSAIDs treatment)

3.NSAIDs decrease the renal blood flow and renal failure may ensue in patients who already suffer from less renal flow due to CHF and Diuretic therapy. Sulindac is safer.

4.Liver failure

5.CNS effects such as drowsiness, dizziness, anxiety, tinnitus, and confusion, that disappear on continuous use. Headache is more common with indomethacin

6.Blood dyscrasias(Rare)

7. Naproxen and ibuprofen are safer than other NSAIDs in producing GI effects

Nabumetone causes lesser gastric irritation

Meclofenamate and Mefenamic acid may cause severe diarrhea

Piroxicam which has a longer duration of action may cause higher gastric bleeding. It should be avoided in elderly patients.

Indomethacin can cause more serious CNS effects than other NSAIDs.

Nonacetylated salicylates such as salsalate, choline salicylate are safer than aspirin in aspirin-sensitive patients as they do not have respiratory effects similar to aspirin.