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Rheumatoid Arthritis Management

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Rheumatoid Arthritis Management

  • Approach
  1. Assess Current disease activity
    1. Morning Stiffness
    2. Synovitis
    3. Fatigue
    4. Erythrocyte Sedimentation Rate
  2. Document Joint Damage
    1. Joint Range of motion and deformities
    2. XRay joint space narrowing and erosions
    3. Functional status
  3. Document Joint Extra-articular manifestations
    1. Nodules
    2. Pulmonary fibrosis
    3. Vasculitis
  • Management
  • General
  1. Non-Pharmacologic
    1. Systemic and articular rest
    2. Physiotherapy
      1. Local Heat Therapy
      2. Local Cold Theraoy
    3. Exercises
      1. Range of Motion
      2. Conditioning
      3. Strengthening Exercises
      4. Tai Chi
    4. Assistive Devices
    5. Patient Education Materials
      1. Arthritis Foundation
      2. American College Rheumatology
  2. Rheumatoid Arthritis Remittive Medications (DMARDs)
    1. Most important agents in Rheumatoid Arthritis
    2. Examples: Methotrexate, Sulfasalazine, Plaquenil
  3. Rheumatoid Arthritis Antiinflammatory Medications (NSAIDs, COX2 Inhibitors)
    1. Used in combination with DMARDs
    2. Limit use of NSAIDs and COX2 Inhibitors once on DMARD >1 month
      1. Decrease to lowest effective dose (preferably use only as needed)
      2. Best use is limiting NSAIDS and COX2 Inhibitors for exacerbations
  4. Other medications
    1. Atorvastatin
      1. Showed modest benefit in clinical improvement
      2. McCarey (2004) Lancet 363:2015-21 [PubMed]
  5. Joint Replacement
    1. Consider for severe joint damage with pain refractory to medical management
  • Management
  • Initial protocol
  1. Indications: New moderate to severe seropositive Rheumatoid Arthritis
  2. Protocol: Start
    1. Prednisone 60 mg daily tapered weekly by 10 mg each week
    2. Methotrexate 15 mg weekly
    3. Folic Acid 1 mg daily
  3. References
    1. Michet (2012) Mayo POIM Conference, Rochester