Rheumatoid arthritis management
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Management of a patient of rheumatoid arthritis.
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Rheumatoid arthritis management
- 1. RHEUMATOID ARTHRITIS DR. ROHIT RAJEEVAN
- 2. MANAGEMEN T
- 3. TREATMENT GOALS • Suppress inflammation • Control symptoms • Prevent joint damage
- 5. • First diagnosis – Initiate Prednisolone 30mg daily • Gradually reduce in 5mg increments every 2 weeks • Withdrawn after 12 weeks • Methotrexate also to be initiated – 15mg weekly initially along with folic acid 5mg weekly • Escalate to max of 25 mg weekly • If inadequate response, or dose related toxicity, then additional DMARD to be added
- 10. SULFASALAZINE • Oral preparation • 1.5 to 3gm daily in twice daily doses • Time to therapeutic effect – 12 weeks • S/E – LFT abnormalities , lymphadenopathy , rash
- 11. HYDROXYCHLOROQUINE • Dose – 200mg twice daily • Time to therapeutic effect – 12 weeks • S/E – Retinal toxicity , maculopathy • Risk of adverse effect increases with treatment duration > 5-7 yr or cumulative dose >1000 gm
- 12. LEFLUNOMIDE • Therapeutic dose – 20mg daily • Time to therapeutic effect 12 weeks • Long half life : 2 weeks! • Dose 10-20 mg daily • S/E – Myelosuppression, elevated transaminases, diarrhea, hypertension
- 13. AZATHIOPRINE • Dose – 2-2.5mg/kg/day twice or thrice daily • Time to therapeutic effect – 12 weeks • S/E – leucopenia, pancytopenia, hemolysis, aplastic anemia.
- 14. GLUCOCORTICOIDS • Oral /IM/IV/Intra-articular • Time to therapeutic effect depends on route of administration • IM / Oral GC’s – effective in managing flares and as a bridge to sDMARDS taking effect • IA injections – symptom control in early disease and flares. Not more frequent than 3 monthly • S/E – cataract, premature coronary artery disease, osteoporosis, muscle atrophy, insulin resistance/diabetes, osteonecrosis. – Fracture reduction therapy should be given
- 15. ANTI TNF ALPHA • Given s/c ( etanercept, adalimumab) or IV (Rituximab) • Time to effect – 2 to 24 weeks or 12-24 wk(Rituxamab) • S/E – infection, headache, nausea, injection site reactions • May trigger a lupus-like syndrome • Can worsen psoriasis in PsA patients (Paradoxical psoriasis) • Rituximab – contraindicated in hypogammaglobulinemia
- 16. ANTI IL-6 BLOCKER (TOCILIZUMAB) • S/C (162mg weekly) or IV (8mg/kg every 4 weeks) • Time to effect : 12 – 24 weeks • Binds to both soluble and membrane bound IL-6 receptors • Licensed as monotherapy; best results when combined with MTX • Caution in diverticulitis patients – increased risk of gut perforation
- 17. CAUTION • All DMARDS ( except HCQs ) to be stopped during any serious infection • Risk vs benefit to be reviewed before considering use in patients with • Chronic infected leg ulcers • Septic arthritis of a native joint – last 12 months • Sepsis of a prosthetic joint within last 12 months • Recurrent or persistent chest infections • Indwelling urinary catheter • Bronchiectasis • Hypogammaglobulinemia
- 18. NON – PHARMACOLOGICAL THERAPY • Physical and occupational therapy such as physiotherapy.
- 19. SURGERY • Synovectomy – joints that fail to respond to systemic therapy and intra-articular injections • Joint replacement therapy • Excision of metatarsal heads in pts with subluxation of MTP joints • Neurosurgery – Atlanto-axial subluxation • Arthrodesis – wrist and ankle – If joint damage +
- 20. THANK YOU