This document discusses the management of rheumatoid arthritis (RA). It provides details on:
- Key features of RA including symptoms, joint involvement, rheumatoid factor levels, and erosions.
- The typical clinical course, with most patients experiencing progressive joint damage over time.
- Treatment principles including early intervention, balancing efficacy and safety, and monitoring.
- Specific treatment options including NSAIDs, DMARDs, immunosuppressants, corticosteroids, and newer biologics.
- Potential complications of long-term RA and its treatment, including NSAID-induced gastropathy. Selective COX-2 inhibitors are presented as a potential solution to reduce gastrointestinal risks.
Interventional pain management pada cancer pain dengan modalitasGivenchy Eunike
This document discusses cancer pain management with interventional techniques using C-arm guidance. It notes that pain is a major concern for many cancer patients. While drug therapy is usually the first approach via the WHO analgesic ladder, 10-20% of patients do not get adequate relief or experience side effects. Interventional techniques like nerve blocks can be considered as additions to medical management for severe, refractory cancer pain, especially in terminal patients. A variety of techniques are described for different sites of cancer pain. Selection of appropriate patients and experience of the interventionist are important factors for effective use of interventional pain management.
This document discusses interventional pain management (IPM) as a specialty focused on diagnosing and treating pain through minimally invasive procedures. It provides an overview of common IPM procedures like diagnostic nerve blocks, radiofrequency ablation, vertebroplasty, and percutaneous discectomy. The document also presents four case studies where IPM procedures like epidurolysis, percutaneous discectomy, vertebroplasty, and radiofrequency rhizotomy successfully treated chronic pain when other options had failed. It concludes that contrary to common beliefs, over 85% of spinal pain causes can be accurately diagnosed through IPM procedures and that IPM can provide long-term relief when pharmacologic treatments and surgery are not suitable options.
This document discusses approaches to reducing acute and chronic peripheral neuropathic pain. It finds that acute neuropathic pain in the perioperative period after procedures like amputation, mastectomy and thoracotomy is under-recognized and may be treatable with agents targeting neuropathic symptoms. Several trials found gabapentinoids, regional anesthesia and antidepressants reduced chronic pain when used in the perioperative period for high-risk surgeries. However, interventions like ketamine and cryoanalgesia were ineffective. The document recommends screening for neuropathic pain and using routine anti-neuropathic drugs perioperatively to potentially decrease the burden of chronic pain.
The document provides New York treatment guidelines for back pain. It recommends x-rays only for certain cases and not as routine testing. MRIs are not recommended in the first 6 weeks except for red flags. CT scans may be used if MRI is contraindicated or for certain radicular pain cases. Epidural steroid injections are recommended for radicular pain lasting over 3 weeks. Physical therapy, medications, and manipulation are recommended treatment options. Surgeries require preauthorization. Objections to payment must be made within 45 days using the proper forms for legal liability, valuation, or failure to follow fee schedules.
Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of both classic and newer chemotherapy agents, affecting 30-40% of cancer patients receiving neurotoxic chemotherapy. CIPN can cause significant costs and reduce quality of life. There are currently no preventive treatments for CIPN, and treatment focuses on reducing or discontinuing the offending chemotherapy agent when CIPN develops, as well as treating neuropathic pain symptoms. More research is still needed to address this challenging complication of cancer treatment.
This document discusses the management of advanced prostate carcinoma in a 65-year-old politician. It outlines the epidemiology, risk factors, pathogenesis, pathology, staging, grading, investigations, and treatment options. The patient has locally advanced or metastatic disease. Treatment aims to be palliative and multidisciplinary, focusing on hormonal manipulation through antiandrogens and LHRH agonists. The prognosis is poor, with progression to hormone resistance typically within 12-18 months and median survival of 2-3 years. Future trends include targeted therapies such as androgen synthesis inhibitors and PSMA-targeted antibodies.
Interventional Techniques For Cancer Pain Management.guest7342323
The document discusses cancer pain management techniques including conservative management and interventional techniques. It covers assessing pain, diagnosing the type and cause of pain, and treating pain using the WHO analgesic ladder as well as more advanced interventional techniques like intraspinal opioid administration, radiofrequency ablation, vertebroplasty, and neurolytic blocks. The goal is to properly diagnose and treat different types of cancer pain to improve patients' quality of life.
Interventional pain management pada cancer pain dengan modalitasGivenchy Eunike
This document discusses cancer pain management with interventional techniques using C-arm guidance. It notes that pain is a major concern for many cancer patients. While drug therapy is usually the first approach via the WHO analgesic ladder, 10-20% of patients do not get adequate relief or experience side effects. Interventional techniques like nerve blocks can be considered as additions to medical management for severe, refractory cancer pain, especially in terminal patients. A variety of techniques are described for different sites of cancer pain. Selection of appropriate patients and experience of the interventionist are important factors for effective use of interventional pain management.
This document discusses interventional pain management (IPM) as a specialty focused on diagnosing and treating pain through minimally invasive procedures. It provides an overview of common IPM procedures like diagnostic nerve blocks, radiofrequency ablation, vertebroplasty, and percutaneous discectomy. The document also presents four case studies where IPM procedures like epidurolysis, percutaneous discectomy, vertebroplasty, and radiofrequency rhizotomy successfully treated chronic pain when other options had failed. It concludes that contrary to common beliefs, over 85% of spinal pain causes can be accurately diagnosed through IPM procedures and that IPM can provide long-term relief when pharmacologic treatments and surgery are not suitable options.
This document discusses approaches to reducing acute and chronic peripheral neuropathic pain. It finds that acute neuropathic pain in the perioperative period after procedures like amputation, mastectomy and thoracotomy is under-recognized and may be treatable with agents targeting neuropathic symptoms. Several trials found gabapentinoids, regional anesthesia and antidepressants reduced chronic pain when used in the perioperative period for high-risk surgeries. However, interventions like ketamine and cryoanalgesia were ineffective. The document recommends screening for neuropathic pain and using routine anti-neuropathic drugs perioperatively to potentially decrease the burden of chronic pain.
The document provides New York treatment guidelines for back pain. It recommends x-rays only for certain cases and not as routine testing. MRIs are not recommended in the first 6 weeks except for red flags. CT scans may be used if MRI is contraindicated or for certain radicular pain cases. Epidural steroid injections are recommended for radicular pain lasting over 3 weeks. Physical therapy, medications, and manipulation are recommended treatment options. Surgeries require preauthorization. Objections to payment must be made within 45 days using the proper forms for legal liability, valuation, or failure to follow fee schedules.
Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of both classic and newer chemotherapy agents, affecting 30-40% of cancer patients receiving neurotoxic chemotherapy. CIPN can cause significant costs and reduce quality of life. There are currently no preventive treatments for CIPN, and treatment focuses on reducing or discontinuing the offending chemotherapy agent when CIPN develops, as well as treating neuropathic pain symptoms. More research is still needed to address this challenging complication of cancer treatment.
This document discusses the management of advanced prostate carcinoma in a 65-year-old politician. It outlines the epidemiology, risk factors, pathogenesis, pathology, staging, grading, investigations, and treatment options. The patient has locally advanced or metastatic disease. Treatment aims to be palliative and multidisciplinary, focusing on hormonal manipulation through antiandrogens and LHRH agonists. The prognosis is poor, with progression to hormone resistance typically within 12-18 months and median survival of 2-3 years. Future trends include targeted therapies such as androgen synthesis inhibitors and PSMA-targeted antibodies.
Interventional Techniques For Cancer Pain Management.guest7342323
The document discusses cancer pain management techniques including conservative management and interventional techniques. It covers assessing pain, diagnosing the type and cause of pain, and treating pain using the WHO analgesic ladder as well as more advanced interventional techniques like intraspinal opioid administration, radiofrequency ablation, vertebroplasty, and neurolytic blocks. The goal is to properly diagnose and treat different types of cancer pain to improve patients' quality of life.
This document provides information on acupuncture, including its origins in China over 2000 years ago, its stated benefits for various conditions like back pain and osteoarthritis, techniques like sham acupuncture, and safety issues. It summarizes several studies on acupuncture for specific conditions like back pain, osteoarthritis of the knee, and postoperative nausea/vomiting. The largest and most well-designed trial found acupuncture effective for osteoarthritis of the knee compared to sham acupuncture. Other studies found acupuncture may provide short-term relief for back pain and help prevent early vomiting after surgery compared to placebo. However, more high-quality research is still needed.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
This document provides information on the NCCN Clinical Practice Guidelines for Adult Cancer Pain. It lists the panel members who developed the guidelines and provides a table of contents for the guidelines. Updates made in Version 1.2013 of the guidelines are summarized, including modifications made to sections on principles of cancer pain management, screening and assessment, management of pain in opioid-naive and tolerant patients, ongoing care, and additional intervention strategies. Footnotes were also updated to reflect FDA guidance on identifying opioid tolerance and new REMS programs.
This document discusses cancer pain management. It notes that 50-90% of oncology inpatients and 35% of outpatients report breakthrough cancer pain. Common causes of cancer pain include bone metastases, visceral metastases, and neuropathic pain. Barriers to effective pain management include clinical, patient-related, and system-related factors as well as racial and ethnic barriers. A thorough pain assessment considers intensity, location, quality, timeline, alleviating factors, and prior medications. Opioids are the mainstay of cancer pain treatment, with short-acting opioids used for breakthrough pain and long-acting for persistent pain.
This document discusses medication options for low back pain. It begins by outlining first-line treatments including non-opioid analgesics like paracetamol and NSAIDs. Combination therapy using both is recommended if pain persists. The document then discusses second-line options if pain involves neuropathic components, such as tricyclic antidepressants, tramadol, or tapentadol. Strong opioids are a fourth-line treatment option if other medications are ineffective.
This document summarizes interventional pain procedures for chronic pain. It describes common origins of lumbar back pain such as degenerative discs and discusses invasive treatment options like surgery, injections, and radiofrequency ablation. Facet joint injections are described as effective for pain originating from facet joints. Epidural injections can provide temporary relief for nerve root compression or spinal stenosis. Medial branch blocks are used diagnostically prior to potential radiofrequency ablation to denervate medial branch nerves controlling facet joint sensation. Psychological assessment and management strategies are also outlined to optimize pain treatment.
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
The system you must inquire more about for this patient is the gastrointestinal system. Her presentation of fatigue, dizziness, anorexia and pale appearance suggests potential blood loss, likely from NSAID-induced peptic ulcer disease given her risk factors of long-term NSAID use and past history of peptic ulcer. A thorough GI exam and labs are warranted to evaluate for potential bleeding.
This document discusses rheumatoid arthritis (RA), including its etiology, classification criteria, clinical features, diagnostic testing, complications, and treatment approaches. RA is a chronic inflammatory disorder that primarily involves synovial joints, with symmetric involvement of hands/feet typically seen. Diagnosis relies on clinical exam showing inflamed joints and laboratory tests like rheumatoid factor and anti-CCP antibodies. If left untreated, RA can cause long-term joint damage and functional disability. Treatment involves medications like NSAIDs, DMARDs, steroids, and biologics to reduce inflammation and prevent structural damage.
This document discusses the management of Potts spine, or spinal tuberculosis. It begins by outlining the progression of spinal cord compression from the anterior column. Current concepts view uncomplicated spinal TB as predominantly a medical disease treated with anti-tubercular therapy (ATT) for 18-24 months. Surgery has specific indications like preventing or treating complications. Investigations include microscopy, culture, histopathology, and newer PCR-based tests. The roles of rest, bracing, and ambulation are discussed for proven cases. Surgical treatment goals include decompression, deformity correction, and stability.
Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation of the joints. The document summarizes the definition, epidemiology, risk factors, pathophysiology, signs and symptoms, complications, diagnosis, and treatment of RA. It describes the clinical presentation of a patient with possible RA and the steps to take which include performing a physical exam, ordering diagnostic tests, making a provisional diagnosis, and referring the patient to a rheumatologist for further evaluation and management. Non-pharmacologic and pharmacologic treatment options for RA are outlined.
The document discusses the challenges of treating patients with early arthritis. It emphasizes the importance of early diagnosis and treatment to prevent long-term joint damage. Within 12 weeks, patients can be classified as having self-limiting or persistent arthritis. For those at risk of persistent disease, treat-to-target strategies using disease-modifying antirheumatic drugs (DMARDs) like methotrexate aim to achieve remission and prevent disability. Prognostic markers help determine who needs long-term treatment. The goal is recognizing and treating erosive arthritis early to optimize outcomes.
Inflammatory arthritis; a quick run through.Ronan Kavanagh
The document provides information about inflammatory arthritis for general practitioners. It discusses common types of inflammatory arthritis GPs may encounter like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It also summarizes tests that may help diagnose inflammatory arthritis and emphasizes the importance of early intervention to prevent joint damage.
The document provides an overview of advancements in the treatment of rheumatoid arthritis. It discusses the disease characteristics and course, classification criteria, treatment objectives and guidelines, and various therapies including biologics. A case example is presented of a patient with joint pains and symptoms meeting classification criteria for rheumatoid arthritis.
Rheumatoid arthritis is a chronic autoimmune disease that causes inflammation and damage to joints. It affects around 1-3% of the global population. While its exact causes are unknown, genetic and environmental factors are believed to play a role. Key symptoms include tender, warm, swollen joints and morning stiffness lasting over an hour. Diagnosis is based on criteria such as the number and location of affected joints, presence of rheumatoid factor or anti-CCP antibodies, and response to treatment. Treatment aims to control symptoms, prevent further joint damage, and improve quality of life using medications such as methotrexate, sulfasalazine, biologics that target cytokines, and newer drugs like tofacitinib. The
This document discusses rheumatoid arthritis (RA), including its diagnosis, management, and treatment. Some key points:
1) RA is a common inflammatory joint disease that affects approximately 1% of the population. It is characterized by persistent inflammatory synovitis leading to joint damage.
2) Diagnosis is based on symptoms like morning stiffness and joint involvement patterns, along with serological markers like rheumatoid factor and anti-CCP antibodies. Disease activity is monitored through clinical exams, labs, and imaging.
3) Treatment involves a multidisciplinary approach including medications like NSAIDs, DMARDs such as methotrexate, steroids, and biologics that target cytokines like TNF-α to reduce
Management of malignant spinal cord compressionShreya Singh
This document summarizes the management of malignant spinal cord compression. It defines MSCC as cancer growth in or near the spine that presses on the spinal cord. Symptoms include back pain, motor deficits, and sensory deficits. Treatment involves corticosteroids, surgery, and radiotherapy. Surgery plus radiotherapy provides better outcomes than radiotherapy alone for patients with good performance status and at least 3 months life expectancy. Standard radiotherapy is 30 Gy in 10 fractions. Shorter courses are used when survival is poor. Surgery may be indicated for instability, intractable pain, or radioresistant cancers.
4_Evaluation and Management of Osteoarthritis.pptbiruktesfaye27
The document provides information on the evaluation and management of osteoarthritis (OA). It presents two case studies: a 65-year-old man with knee pain likely due to past knee injury, and a 75-year-old woman with OA in both knees, hips, and thumbs likely due to family history and genetics. The document discusses risk factors for OA, symptoms, diagnostic studies, pharmacological and non-pharmacological treatment options including exercise, topical agents, braces, and surgery.
Evaluation and Management of Osteoarthritis (2).pptbiruktesfaye27
This document provides information on the evaluation and management of osteoarthritis (OA). It presents two case studies: a 65-year-old man with knee pain likely due to past knee injury, and a 75-year-old woman with OA in both knees, hips, and thumbs likely due to family history and age. The document discusses risk factors for OA, symptoms, diagnostic studies, pharmacological and non-pharmacological treatment options including exercise, topical agents, analgesics and surgery. Management involves a stepped approach starting with non-drug options and progressing to more invasive treatments if needed.
This document provides an overview of inflammatory arthritis, including:
1. It defines inflammatory arthritis and categorizes the different types. It discusses the history, physical exam findings, and initial lab/radiological evaluations used to diagnose suspected cases.
2. The document outlines the distinguishing features between inflammatory, mechanical, and non-inflammatory arthritis. It also discusses the patterns of joint involvement and distributions that can help differentiate diseases.
3. Laboratory tests that may be useful in the evaluation of inflammatory arthritis are described, including acute phase reactants, rheumatoid factor, and anti-CCP antibodies. The sensitivities and specificities of these tests are provided.
This document provides an overview of inflammatory arthritis, including rheumatoid arthritis. It discusses the history and physical examination findings, defines categories of inflammatory arthritis, and outlines the initial laboratory and radiological evaluation. It also covers the management of inflammatory arthritis, focusing on rheumatoid arthritis. Key points include distinguishing features of inflammatory vs mechanical and inflammatory vs non-inflammatory arthritis, common joints affected in rheumatoid arthritis, extra-articular manifestations, diagnostic criteria, and treatment approaches including NSAIDs, steroids, DMARDs, immunosuppressants, biologics, and surgery.
This document provides information on acupuncture, including its origins in China over 2000 years ago, its stated benefits for various conditions like back pain and osteoarthritis, techniques like sham acupuncture, and safety issues. It summarizes several studies on acupuncture for specific conditions like back pain, osteoarthritis of the knee, and postoperative nausea/vomiting. The largest and most well-designed trial found acupuncture effective for osteoarthritis of the knee compared to sham acupuncture. Other studies found acupuncture may provide short-term relief for back pain and help prevent early vomiting after surgery compared to placebo. However, more high-quality research is still needed.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
This document provides information on the NCCN Clinical Practice Guidelines for Adult Cancer Pain. It lists the panel members who developed the guidelines and provides a table of contents for the guidelines. Updates made in Version 1.2013 of the guidelines are summarized, including modifications made to sections on principles of cancer pain management, screening and assessment, management of pain in opioid-naive and tolerant patients, ongoing care, and additional intervention strategies. Footnotes were also updated to reflect FDA guidance on identifying opioid tolerance and new REMS programs.
This document discusses cancer pain management. It notes that 50-90% of oncology inpatients and 35% of outpatients report breakthrough cancer pain. Common causes of cancer pain include bone metastases, visceral metastases, and neuropathic pain. Barriers to effective pain management include clinical, patient-related, and system-related factors as well as racial and ethnic barriers. A thorough pain assessment considers intensity, location, quality, timeline, alleviating factors, and prior medications. Opioids are the mainstay of cancer pain treatment, with short-acting opioids used for breakthrough pain and long-acting for persistent pain.
This document discusses medication options for low back pain. It begins by outlining first-line treatments including non-opioid analgesics like paracetamol and NSAIDs. Combination therapy using both is recommended if pain persists. The document then discusses second-line options if pain involves neuropathic components, such as tricyclic antidepressants, tramadol, or tapentadol. Strong opioids are a fourth-line treatment option if other medications are ineffective.
This document summarizes interventional pain procedures for chronic pain. It describes common origins of lumbar back pain such as degenerative discs and discusses invasive treatment options like surgery, injections, and radiofrequency ablation. Facet joint injections are described as effective for pain originating from facet joints. Epidural injections can provide temporary relief for nerve root compression or spinal stenosis. Medial branch blocks are used diagnostically prior to potential radiofrequency ablation to denervate medial branch nerves controlling facet joint sensation. Psychological assessment and management strategies are also outlined to optimize pain treatment.
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
The system you must inquire more about for this patient is the gastrointestinal system. Her presentation of fatigue, dizziness, anorexia and pale appearance suggests potential blood loss, likely from NSAID-induced peptic ulcer disease given her risk factors of long-term NSAID use and past history of peptic ulcer. A thorough GI exam and labs are warranted to evaluate for potential bleeding.
This document discusses rheumatoid arthritis (RA), including its etiology, classification criteria, clinical features, diagnostic testing, complications, and treatment approaches. RA is a chronic inflammatory disorder that primarily involves synovial joints, with symmetric involvement of hands/feet typically seen. Diagnosis relies on clinical exam showing inflamed joints and laboratory tests like rheumatoid factor and anti-CCP antibodies. If left untreated, RA can cause long-term joint damage and functional disability. Treatment involves medications like NSAIDs, DMARDs, steroids, and biologics to reduce inflammation and prevent structural damage.
This document discusses the management of Potts spine, or spinal tuberculosis. It begins by outlining the progression of spinal cord compression from the anterior column. Current concepts view uncomplicated spinal TB as predominantly a medical disease treated with anti-tubercular therapy (ATT) for 18-24 months. Surgery has specific indications like preventing or treating complications. Investigations include microscopy, culture, histopathology, and newer PCR-based tests. The roles of rest, bracing, and ambulation are discussed for proven cases. Surgical treatment goals include decompression, deformity correction, and stability.
Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation of the joints. The document summarizes the definition, epidemiology, risk factors, pathophysiology, signs and symptoms, complications, diagnosis, and treatment of RA. It describes the clinical presentation of a patient with possible RA and the steps to take which include performing a physical exam, ordering diagnostic tests, making a provisional diagnosis, and referring the patient to a rheumatologist for further evaluation and management. Non-pharmacologic and pharmacologic treatment options for RA are outlined.
The document discusses the challenges of treating patients with early arthritis. It emphasizes the importance of early diagnosis and treatment to prevent long-term joint damage. Within 12 weeks, patients can be classified as having self-limiting or persistent arthritis. For those at risk of persistent disease, treat-to-target strategies using disease-modifying antirheumatic drugs (DMARDs) like methotrexate aim to achieve remission and prevent disability. Prognostic markers help determine who needs long-term treatment. The goal is recognizing and treating erosive arthritis early to optimize outcomes.
Inflammatory arthritis; a quick run through.Ronan Kavanagh
The document provides information about inflammatory arthritis for general practitioners. It discusses common types of inflammatory arthritis GPs may encounter like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. It also summarizes tests that may help diagnose inflammatory arthritis and emphasizes the importance of early intervention to prevent joint damage.
The document provides an overview of advancements in the treatment of rheumatoid arthritis. It discusses the disease characteristics and course, classification criteria, treatment objectives and guidelines, and various therapies including biologics. A case example is presented of a patient with joint pains and symptoms meeting classification criteria for rheumatoid arthritis.
Rheumatoid arthritis is a chronic autoimmune disease that causes inflammation and damage to joints. It affects around 1-3% of the global population. While its exact causes are unknown, genetic and environmental factors are believed to play a role. Key symptoms include tender, warm, swollen joints and morning stiffness lasting over an hour. Diagnosis is based on criteria such as the number and location of affected joints, presence of rheumatoid factor or anti-CCP antibodies, and response to treatment. Treatment aims to control symptoms, prevent further joint damage, and improve quality of life using medications such as methotrexate, sulfasalazine, biologics that target cytokines, and newer drugs like tofacitinib. The
This document discusses rheumatoid arthritis (RA), including its diagnosis, management, and treatment. Some key points:
1) RA is a common inflammatory joint disease that affects approximately 1% of the population. It is characterized by persistent inflammatory synovitis leading to joint damage.
2) Diagnosis is based on symptoms like morning stiffness and joint involvement patterns, along with serological markers like rheumatoid factor and anti-CCP antibodies. Disease activity is monitored through clinical exams, labs, and imaging.
3) Treatment involves a multidisciplinary approach including medications like NSAIDs, DMARDs such as methotrexate, steroids, and biologics that target cytokines like TNF-α to reduce
Management of malignant spinal cord compressionShreya Singh
This document summarizes the management of malignant spinal cord compression. It defines MSCC as cancer growth in or near the spine that presses on the spinal cord. Symptoms include back pain, motor deficits, and sensory deficits. Treatment involves corticosteroids, surgery, and radiotherapy. Surgery plus radiotherapy provides better outcomes than radiotherapy alone for patients with good performance status and at least 3 months life expectancy. Standard radiotherapy is 30 Gy in 10 fractions. Shorter courses are used when survival is poor. Surgery may be indicated for instability, intractable pain, or radioresistant cancers.
4_Evaluation and Management of Osteoarthritis.pptbiruktesfaye27
The document provides information on the evaluation and management of osteoarthritis (OA). It presents two case studies: a 65-year-old man with knee pain likely due to past knee injury, and a 75-year-old woman with OA in both knees, hips, and thumbs likely due to family history and genetics. The document discusses risk factors for OA, symptoms, diagnostic studies, pharmacological and non-pharmacological treatment options including exercise, topical agents, braces, and surgery.
Evaluation and Management of Osteoarthritis (2).pptbiruktesfaye27
This document provides information on the evaluation and management of osteoarthritis (OA). It presents two case studies: a 65-year-old man with knee pain likely due to past knee injury, and a 75-year-old woman with OA in both knees, hips, and thumbs likely due to family history and age. The document discusses risk factors for OA, symptoms, diagnostic studies, pharmacological and non-pharmacological treatment options including exercise, topical agents, analgesics and surgery. Management involves a stepped approach starting with non-drug options and progressing to more invasive treatments if needed.
This document provides an overview of inflammatory arthritis, including:
1. It defines inflammatory arthritis and categorizes the different types. It discusses the history, physical exam findings, and initial lab/radiological evaluations used to diagnose suspected cases.
2. The document outlines the distinguishing features between inflammatory, mechanical, and non-inflammatory arthritis. It also discusses the patterns of joint involvement and distributions that can help differentiate diseases.
3. Laboratory tests that may be useful in the evaluation of inflammatory arthritis are described, including acute phase reactants, rheumatoid factor, and anti-CCP antibodies. The sensitivities and specificities of these tests are provided.
This document provides an overview of inflammatory arthritis, including rheumatoid arthritis. It discusses the history and physical examination findings, defines categories of inflammatory arthritis, and outlines the initial laboratory and radiological evaluation. It also covers the management of inflammatory arthritis, focusing on rheumatoid arthritis. Key points include distinguishing features of inflammatory vs mechanical and inflammatory vs non-inflammatory arthritis, common joints affected in rheumatoid arthritis, extra-articular manifestations, diagnostic criteria, and treatment approaches including NSAIDs, steroids, DMARDs, immunosuppressants, biologics, and surgery.
Rheumatoid Arthritis Pathology, C/F and Diagnosis and Mx.pptBharath Kal
Rheumatoid arthritis is a chronic inflammatory disorder characterized by symmetric polyarthritis of unknown etiology. Genetics and environmental factors contribute to its pathogenesis. It is more prevalent in women and has a worldwide prevalence of around 0.5-1% in adults. Treatment involves NSAIDs, glucocorticoids, conventional DMARDs like methotrexate, and biologic DMARDs that target molecules like TNF-α. The goal of treatment is to control inflammation, reduce joint damage, and prevent disability. Monitoring of disease activity and progression is important for managing rheumatoid arthritis effectively over the long term.
This document provides an overview of rheumatoid arthritis (RA), including its aetiology, pathophysiology, clinical evaluation, investigations, treatment, and complications. RA is an autoimmune disease that commonly involves the small joints of the hands and feet, causing pain, swelling and stiffness. Early diagnosis and treatment with medications such as corticosteroids and disease-modifying drugs can slow disease progression and reduce joint damage. Treatment involves a multidisciplinary approach including medications, physical therapy, and sometimes surgery to correct deformities.
This document provides an overview of rheumatoid arthritis (RA) and evaluating patients with rheumatic diseases. It discusses evaluating joint swelling based on distribution, acute vs chronic symptoms, and evidence of systemic inflammation. Common tests in rheumatology like joint aspiration and antibodies are also outlined. RA is introduced as a chronic inflammatory disease affecting the synovium. Diagnostic criteria, manifestations, associated syndromes, laboratory findings, and treatment options for RA are summarized. Complications of RA like atlantoaxial subluxation are also mentioned.
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Similar to 3 evaluation and management of rheumatoid arthritis (20)
The larynx is a hollow structure located in the neck that contains the vocal cords. It functions in respiration, swallowing, and voice production. The larynx has a cartilaginous skeleton including the thyroid, cricoid, arytenoid, and epiglottic cartilages connected by membranes and ligaments. It is supplied by nerves including the recurrent laryngeal nerve which controls the vocal cords. During phonation, expired air causes the vocal cords to vibrate and resonate within the larynx and pharynx to produce voice.
1. The document discusses various laboratory tests used to evaluate liver disease, including tests of liver cell injury (transaminases), cholestasis (alkaline phosphatase, bilirubin), and liver function (albumin, clotting factors).
2. Transaminases indicate recent liver cell death while tests of cholestasis show impaired bile flow. Together the pattern of abnormalities on these tests can suggest the general type of liver disease.
3. The degree of elevation on tests and the specific abnormalities seen provide clues about the chronicity, severity and underlying cause of liver disease. Interpreting various test results in combination is important for diagnosis.
This document discusses glycogen storage disorders (GSDs), which are caused by defects in glycogen metabolism. It describes the various enzymes involved and the biochemical tests used to diagnose different types of GSDs. Predominantly hepatic GSDs include defects in glucose-6-phosphatase (GSD I), debranching enzyme (GSD III), branching enzyme (GSD IV) and phosphorylase (GSD VI, IX). Muscle-affecting GSDs involve acid α-glucosidase deficiency (GSD II/Pompe disease), muscle phosphorylase (GSD V), and muscle phosphofructokinase (GSD VII). Diagnosis involves tests on red blood cells
I do not have enough context to answer these review questions. The document provided is a summary of cholesterol synthesis and regulation. It does not contain answers to these specific questions.
Cholesterol is an important animal steroid that maintains membrane fluidity and is the parent molecule for bile acids, steroid hormones, and vitamin D3. The liver plays a central role in regulating cholesterol homeostasis through synthesis and excretion. Cholesterol synthesis is regulated by the rate-limiting enzyme HMG CoA reductase, which is controlled by sterol-dependent and -independent mechanisms as well as hormones like insulin and glucagon. Excess cholesterol is excreted in bile and eliminated in feces, while hypercholesterolemia can be treated with statin drugs that inhibit HMG CoA reductase or plant sterols that block cholesterol absorption.
Cirrhosis is a diffuse process characterized by liver fibrosis and conversion to abnormal nodules. It is most commonly caused by alcoholism and viral hepatitis. Complications include portal hypertension, ascites, bleeding, and hepatic encephalopathy. Diagnosis involves blood tests of liver function and imaging. Treatment focuses on managing complications through dietary changes, medications, procedures, and potentially transplantation. Prognosis depends on severity as assessed by scales like Child-Pugh and MELD scores.
Glycogen storage disease (GSD) occurs due to defects in enzymes involved in glycogen synthesis or breakdown, leading to excess glycogen storage. There are 11 known types classified by the affected enzyme and tissue. Symptoms vary by type but can include hypoglycemia, liver and muscle involvement, and exercise intolerance. Treatment depends on type and may include dietary changes, enzyme replacement therapy, or liver transplantation. Prenatal testing is available for some types.
This document discusses cholesterol metabolism and ways to lower cholesterol levels. It covers the sources of cholesterol from diet and de novo synthesis. The key enzyme in cholesterol synthesis, HMG CoA reductase, is regulated both short-term by phosphorylation and long-term by SREBP-2 which responds to cellular sterol levels. Statins are commonly used to lower cholesterol by decreasing the activity of HMG CoA reductase. Other strategies mentioned include bile sequestering agents which bind bile acids, increasing cholesterol use to make more bile acids, and niacin which inhibits VLDL excretion from the liver.
This document provides information on osteoarthritis (OA) and rheumatoid arthritis (RA). It defines OA as the most common form of joint disease, affecting over 90% of adults by age 40. Risk factors include aging, obesity, and joint injury from overuse. RA is a chronic systemic inflammatory disease that affects the synovial joints, with potential extra-articular manifestations. RA is believed to have an autoimmune cause and is associated with the presence of rheumatoid factor. Both diseases can cause pain, stiffness, and loss of physical function in affected joints. Treatment involves managing symptoms, maintaining function, and may include medications, exercise, joint protection, and sometimes surgery.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints, resulting in pain, swelling, stiffness and destruction of cartilage and bone. It most commonly affects small joints in the hands and feet. Conventional treatments include NSAIDs, disease-modifying anti-rheumatic drugs like methotrexate, and corticosteroids. However, these may have side effects or lose effectiveness over time. Biological therapies targeting cytokines like TNF-α have been developed as alternative treatments and include anti-TNF agents infliximab, etanercept and adalimumab, as well as the IL-6 receptor antagonist tocilizumab. These biologics provide more effective relief of symptoms for many
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints, resulting in pain, swelling, stiffness and destruction of cartilage and bone. It most commonly affects small joints in the hands and feet. Conventional treatments include NSAIDs, disease-modifying anti-rheumatic drugs like methotrexate, and corticosteroids. However, these may have side effects or lose effectiveness over time. Biological therapies targeting cytokines like TNF-α have significantly improved treatment outcomes, with anti-TNF agents infliximab, etanercept and adalimumab being widely used options.
Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints and surrounding tissues. It affects around 1% of adults and is more common in women. The prevalence and incidence increases with age, peaking between 40-60 years old. Symptoms include morning stiffness, arthritis in 3 or more joints including the hands, and symmetric joint involvement. Lupus is an autoimmune disease that causes inflammation in tissues throughout the body including the skin, heart, lungs, and kidneys. Seronegative spondyloarthropathies are a group of related disorders including Reiter's syndrome, ankylosing spondylitis, psoriatic arthritis, and arthritis associated with inflammatory bowel disease. They
Rheumatoid arthritis is an autoimmune disease that causes inflammation and destruction of joints, tendons and bones. It results in joint deformity and immobilization. Symptoms include morning stiffness, symmetrical joint swelling, fever and fatigue. Diagnosis involves blood tests for inflammatory markers like ESR and CRP, as well as antibody tests. Treatment includes medications like NSAIDs, DMARDs, corticosteroids and biologics to reduce inflammation and slow joint destruction. Lifestyle changes such as exercise, nutrition, braces and surgery can also help manage symptoms and improve quality of life.
The document summarizes blood circulation to the brain. It describes how blood is supplied to the brain through two internal carotid arteries and two vertebral arteries that form a complex network called the circle of Willis. It then discusses the major arteries that branch off from this circle - the anterior, middle, and posterior cerebral arteries - and the regions of the brain each supplies. It notes that decreases in blood flow through these arteries can cause impairments or weaknesses on the opposite side of the body.
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Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
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Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
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Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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4. Rheumatoid Arthritis:
Key Features
• Symptoms >6 weeks’ duration
• Often lasts the remainder of the patient’s life
• Inflammatory synovitis
• Palpable synovial swelling
• Morning stiffness >1 hour, fatigue
• Symmetrical and polyarticular (>3 joints)
• Typically involves wrists, MCP, and PIP joints
• Typically spares certain joints
• Thoracolumbar spine
• DIPs of the fingers and IPs of the toes
5. Rheumatoid Arthritis:
Key Features (cont’d)
• May have nodules: subcutaneous or periosteal at
pressure points
• Rheumatoid factor
• 45% positive in first 6 months
• 85% positive with established disease
• Not specific for RA, high titer early is a bad
sign
• Marginal erosions and joint space narrowing on
x-ray
Adapted from Arnett, et al. Arth Rheum. 1988;31:315–324.
6. Rheumatoid Arthritis: PIP Swelling
Swelling is confined to
the area of the joint
capsule
Synovial thickening
feels like a firm
sponge
7. Rheumatoid Arthritis:
Ulnar Deviation and MCP Swelling
An across-the-room
diagnosis
Prominent ulnar
deviation in the right
hand
MCP and PIP swelling
in both hands
Synovitis of left wrist
8. Clinical Course of RA
Type 1 = Self-limited—5% to 20%
Type 2 = Minimally progressive—5% to 20%
Type 3 = Progressive—60% to 90%
0
1
2
3
4
0 0.5 1 2 3 4 6 8 16
Type 1
Type 2
Type 3
Years
SeverityofArthritis
Pincus. Rheum Dis Clin North Am. 1995;21:619.
9. Pincus, et al. Rheum Dis Clin North Am. 1993;19:123–151.
Rheumatoid Arthritis: Typical Course
• Damage occurs early in most patients
• 50% show joint space narrowing or erosions in
the first 2 years
• By 10 years, 50% of young working patients
are disabled
• Death comes early
• Multiple causes
• Compared to general population
• Women lose 10 years, men lose 4 years
10. Rheumatoid Arthritis
• Key points:
• The sicker they are and the faster they get that
way, the worse the future will be
• Early intervention can make a difference
• Essential to establish a treatment plan early in
the disease
11. Rheumatoid Arthritis:
Treatment Principles
Confirm the diagnosis
Determine where the patient stands in the
spectrum of disease
When damage begins early, start aggressive
treatment early
Use the safest treatment plan that matches the
aggressiveness of the disease
Monitor treatment for adverse effects
Monitor disease activity, revise Rx as needed
12. Critical Elements of a Treatment Plan:
Assessment
• Assess current activity
• Morning stiffness, synovitis, fatigue, ESR
• Document the degree of damage
• ROM and deformities
• Joint space narrowing and erosions on x-ray
• Functional status
• Document extra-articular manifestations
• Nodules, pulmonary fibrosis, vasculitis
• Assess prior Rx responses and side effects
13. Critical Elements of a Treatment Plan:
Therapy
• Education
• Build a cooperative long-term relationship
• Use materials from the Arthritis Foundation and
the ACR
• Assistive devices
• Exercise
• ROM, conditioning, and strengthening exercises
• Medications
• Analgesic and/or anti-inflammatory
• Immunosuppressive, cytotoxic, and biologic
• Balance efficacy and safety with activity
14. Rheumatoid Arthritis:
Drug Treatment Options
• NSAIDs
• Symptomatic relief, improved function
• No change in disease progression
• Low-dose prednisone (10 mg qd)
• May substitute for NSAID
• Used as bridge therapy
• If used long term, consider prophylactic
treatment for osteoporosis
• Intra-articular steroids
• Useful for flares
Paget. Primer on Rheum Dis. 11th edition. 1997:168.
15. Rheumatoid Arthritis:
Treatment Options
• Disease modifying drugs (DMARDs)
• Minocycline
• Modest effect, may work best early
• Sulfasalazine, hydroxychloroquine
• Moderate effect, low cost
• Intramuscular gold
• Slow onset, decreases progression, rare
remission
• Requires close monitoring
Alarcon. Rheum Dis Clin North Am. 1998;24:489–499.
Paget. Primer on Rheum Dis. 11th edition. 1997:168.
16. Paget. Primer on Rheum Dis. 11th edition. 1997:168.
Rheumatoid Arthritis:
Treatment Options (cont’d)
• Immunosuppressive drugs
• Methotrexate
• Most effective single DMARD
• Good benefit-to-risk ratio
• Azathioprine
• Slow onset, reasonably effective
• Cyclophosphamide
• Effective for vasculitis, less so for arthritis
• Cyclosporine
• Superior to placebo, renal toxicity
17. Rheumatoid Arthritis: Treatment
New Options—Combinations
Methotrexate,
hydroxychloroquine,
and sulfasalazine
Superior to any one or
two alone for ACR
50% improvement
response and
maintenance of the
response
Side effects no greater0
10
20
30
40
50
60
70
80
90
2-Year Outcome
PercentWith50%ACRResponse
Triple
RX
SSZ+
HCQ
MTX
18. Rheumatoid Arthritis: Treatment
New Options—Combinations (cont’d)
• Step-down prednisone with sulfasalazine and
low-dose methotrexate*
• Superior to sulfasalazine in early disease*
• Methotrexate + hydroxychloroquine or
methotrexate + cyclosporine†
• May have additive beneficial effects†
*Boers, et al. Lancet. 1997;350:309–318.
†Stein, et al. Arth Rheum. 1997;40:1721–1723.
19. Rheumatoid Arthritis: Treatment
Options—New DMARDs
• Leflunomide
• Pyrimidine inhibitor
• Effect and side effects similar to those of MTX
• Etanercept
• Soluble TNF receptor, blocks TNF
• Rapid onset, quite effective in refractory
patients in short-term trials and in combination
with MTX
• Injection site reactions, long-term effects
unknown, expensive
Rozman. J Rheumatol. 1998;53:27–32.
Moreland. Rheum Dis Clin North Am. 1998;24:579–591.
20. Rheumatoid Arthritis: Monitoring
Treatment With DMARDs
• These drugs need frequent monitoring
• Blood, liver, lung, and kidney are frequent sites of
adverse effects
• Interval of laboratory testing varies with the drug
• 4- to 8-week intervals are commonly needed
• Most patients need to be seen 3 to 6 times a year
21. Rheumatoid Arthritis:
Adverse Effects of DMARDs
Drug Hem Liver Lung Renal Infect Ca Other
HCQ + - - - - - Eye
SSZ + + + - - - GI Sx
Gold ++ - + ++ - - Rash
MTX + + ++ - ++ ? Mucositis
AZA ++ + - - ++ + Pancreas
PcN ++ + + ++ - - SLE, MG
Cy +++ - - - +++ +++ Cystitis
CSA + ++ - +++ ++ + HTN
TNF* - - - - ? ? Local
Lef* ++ ++ - - ? ?
*Long-term data not available.
Adapted from Paget. Primer on Rheum Dis. 11th edition. 1997:168.
23. Rheumatoid Arthritis: Case 1
34-year-old woman with 5-year history of RA
Morning stiffness = 30 minutes
Synovitis: 1+ swelling of MCP, PIP, wrist, and
MTP joints
Normal joint alignment
Rheumatoid factor positive
No erosions seen on x-rays
24. Rheumatoid Arthritis: Case 1 (cont’d)
• Assessment
• Current activity—mild
• No sign of damage after 5 years
• Type 2 minimally progressive course
• Treatment
• NSAID + safer, less potent drugs, eg,
• Hydroxychloroquine, minocycline, or
sulfasalazine
• Education + ROM, conditioning, and
strengthening exercises
25. Rheumatoid Arthritis: Case 2
34-year-old woman with 1-year history of RA
Morning stiffness = 90 minutes
Synovitis: 1+ to 2+ swelling of MCP, PIP, wrist,
knee, and MTP joints
Normal joint alignment
RF positive
Small erosions of the right wrist and two MCP
joints seen on x-rays
27. A. Soft-tissue swelling,
no erosions
B. Thinning of the cortex
on the radial side and
minimal joint space
narrowing
C. Marginal erosion at
the radial side of the
metacarpal head with
joint space narrowing
How fast is joint damage progressing?
Rheumatoid Arthritis: Case 2 (cont’d)
ACR Clinical Slide Collection, 1997.
28. Rheumatoid Arthritis: Case 2 (cont’d)
• Assessment of case 2
• Moderate disease activity
• Many joints involved
• Clear radiologic signs of joint destruction early
in disease course
• Type 3 progressive course
• Treatment should be more aggressive
• NSAID, MTX, SSZ, and hydroxychloroquine
would be a good choice
29. Rheumatoid Arthritis: Case 3
• 34-year-old woman with 3-year history of RA
• Morning stiffness = 3 hours
• 2 to 3+ swelling of MCP, PIP, wrist, elbow,
knee, and MTP joints
• Ulnar deviation, swan neck deformities,
decreased ROM at wrists, nodules on elbows
• RF positive, x-rays show erosions of wrists and
MCP joints bilaterally
• Currently on low-dose prednisone + MTX, SSZ,
and hydroxychloroquine
30. Rheumatoid Arthritis: Case 3 (cont’d)
• Assessment
• Very active disease in spite of aggressive
combination therapy
• Evidence of extensive joint destruction
• Treatment options are many
• Step-down oral prednisone, 60 mg qd tapered
to 10 mg qd over 5 weeks, can be used for
immediate relief of symptoms
• Use other cytotoxics or cyclosporine
• Consider TNF inhibitor or leflunomide
31. Rheumatoid Arthritis:
Treatment Plan Summary
• A variety of treatment options are available
• Treatment plan should match
• The current disease activity
• The documented and anticipated pace of joint
destruction
• Consider a rheumatology consult to help design a
treatment plan
33. RA: Unknown Case 1
68-year-old woman with 3-year history of RA is
squeezed into your schedule as a new patient
She presents with 4 weeks of increasing fatigue,
dizziness, dyspnea, and anorexia
Her joint pain and stiffness are mild and
unchanged
Managed with ibuprofen and hydroxychloroquine
until 4 months ago, when a flare caused a switch
to piroxicam and prednisone
34. RA: Unknown Case 1 (cont’d)
Past history: Peptic ulcer 10 years ago and mild
hypertension
Exam shows a thin, pale apathetic woman with
Temp 98.4ºF, BP 110/65, pulse 110 bpm
Symmetrical 1+ synovitis of the wrist, MCP, PIP,
and MTP joints
Exam of the heart, lungs, and abdomen is
unremarkable
35. RA: Unknown Case 1 (cont’d)
You are falling behind in your schedule
What system must you inquire more
about today?
A. Cardiovascular
B. Neuropsychological
C. Endocrine
D. Gastrointestinal
36. RA: Unknown Case 1 (cont’d)
Don’t Miss It
NSAID gastropathy is sneaky and can be fatal
37. RA: Unknown Case 1 (cont’d)
• Clues of impending disaster
• High risk for NSAID gastropathy
• Presentation suggestive of blood loss
• Pale, dizzy, weak
• Tachycardia, low blood pressure
• No evidence of flare in RA to explain recent
symptoms of increased fatigue
38. Singh. Am J Med. 1998;105(suppl B):31S–38S.
NSAID Gastropathy
Gastric ulcers are more common than duodenal
ulcers
No reliable warning signs
80% of serious events occur without prior
symptoms
Risk of hospitalization for NSAID ulcers in RA is
2.5 to 5.5 times higher than general population
107,000 patients are hospitalized and 16,000
deaths occur annually in the US because of
NSAID-induced gastrointestinal complications
39. Singh. Am J Med. 1998;105(suppl B):31S–38S.
Key Point: Know the Risk Factors
for NSAID Ulcers
Older age
Prior history of peptic ulcer or GI symptoms with
NSAIDs
Concomitant use of prednisone
NSAID dose: More prostaglandin suppression =
greater risk of serious events
Disability level: The sicker the patient the higher
the risk
40. Hawkey. N Engl J Med. 1998;338:727–734.
NSAID Gastropathy: Treatment
• Acute bleed or perforation
• Stop NSAID
• Endoscopy or surgery
• Start omeprazole
• Ulcer without bleed or perforation, and needs or
wants continued NSAID
• Omeprazole 20 mg qd—76% healed
• Misoprostol 200 µg qid—71% healed
41. NSAID Gastropathy: Prevention
• Avoid the problem
• Stop the NSAID and use alternative treatment
• Low-dose prednisone
• Acetaminophen
• Nonacetylated salicylates
• Use a selective cyclooxygenase-2 inhibitor
42. Differential Expression of COX-1 and COX-2
Cyclooxygenase (COX) enzymes are a key step in
prostaglandin production
COX-1
Housekeeping
most tissues
stomach
platelets
kidney
Inducible
macrophages
Furst. Rheum Grand Rounds. 1998;1:1.
Needleman, et al. J Rheumatol. 1997;24(suppl 49):6–8.
COX-2
Inducible
immune system,
ovary, amniotic fluid,
bone, kidney,
colorectal tumors
Housekeeping
brain, kidney
43. Selective COX-2 Suppression:
A Potentially Elegant Solution
• Traditional NSAIDs at full therapeutic doses inhibit
both enzymes
• Most have greater effect on COX-1 than COX-2
• The new drugs are highly selective for COX-2
• >300-fold more effective against COX-2
• This difference allows
• Major reduction in COX-2 production of
proinflammatory PGs
• Sparing of COX-1–produced housekeeping
PGs
Vane, Botting. Am J Med. 1998;104(suppl 3A):2S–8S.
44. NSAID Gastropathy: Prevention
• Short-term (1 to 4 weeks) clinical studies with
COX-2 inhibitor in patients with OA and RA*
• Significant control of arthritis symptoms
• Fewer endoscopic ulcers
• No effect on platelet aggregation or
bleeding time
• Insufficient data to determine risk of serious
events or safety in high-risk populations
• Celecoxib and rofecoxib have been approved;
meloxicam and other selective inhibitors are
currently in clinical trials
*Celecoxib.
Simon, et al. Arth Rheum. 1998;41:1591–1602.
45. NSAID Gastropathy: Prevention (cont’d)
• Counteract the problem
• Misoprostol
• Reduction of serious events by 40%
• Results best with 200 µg qid
• Side effects: diarrhea and uterine cramps
• Avoid if pregnancy risk is present
• Omeprazole
• Recent studies show 72% to 78% reduction in
all ulcers when used for primary prevention at
20 mg qd
Scheiman, Isenberg. Am J Med. 1998;105(suppl 5A):32S–38S.
Hawkey. Am J Med. 1998;104(suppl 3A):67S–74S.
46. NSAID Gastropathy: Key Points
• Keep it in mind
• Know the risk factors
• The best way to treat it is to prevent it
• Avoid it: Use acetaminophen, salsalate, or a
selective COX-2 inhibitor
• Counteract it: Omeprazole or misoprostol
• Antacids and H2 blockers are not the answer
• May mask symptoms but do not prevent
serious events
47. Rheumatoid Arthritis: Unknown Case 2
You are doing a preop physical for a routine
cholecystectomy on a 43-year-old woman with
RA since age 20. PMH includes bilateral THAs
and left TKA. No other medical problems.
Current meds: NSAID, low-dose prednisone,
MTX, and HCQ
General physical exam normal
MS exam, extensive deformities, mild synovitis
In addition to routine tests, what test should be
ordered before surgery?
48. Don’t Miss It
Subluxation of C1 on C2
RA can cause asymptomatic instability of the neck
Manipulation under anesthesia can cause spinal cord injury
49. Clues for C1-C2 Subluxation
• Long-standing rheumatoid arthritis or JRA
• May have NO symptoms
• C2-C3 radicular pain in the neck and occiput
• Spinal cord compression
• Quadriparesis or paraparesis
• Sphincter dysfunction
• Sensory deficits
• TIAs secondary to compromise of the vertebral
arteries
Anderson. Primer on Rheum Dis. 11th edition. 1997:161.
50. Rheumatoid Arthritis:
Special Considerations on Preop Exam
• C1-C2 subluxation
• Cricoarytenoid arthritis with adductor spasm of
the vocal cords and a narrow airway
• Pulmonary fibrosis
• Risk for GI bleeding
• Need for stress steroid coverage
• Discontinue NSAIDs several days preop
• Discontinue methotrexate 1 to 2 weeks preop
• Cover with analgesic meds or if necessary
short-term, low-dose steroid if RA flares
51. Rheumatoid Arthritis: Unknown Case 3
52-year-old man with destructive RA treated with
NSAID and low-dose prednisone. MTX started 4
months ago, now 15 mg/wk
Presents with 3-week history of fever, dry cough,
and increasing shortness of breath
Exam: Low-grade fever, fine rales in both lungs,
normal CBC and liver enzymes, low albumin,
diffuse interstitial infiltrates on chest x-ray
52. RA: Unknown Case 3 (cont’d)
What would you do?
A. Culture, treat with antibiotic for bacterial
pneumonia
B. Culture, give cough suppressant for viral
pneumonia and watch
C. Give oral steroid for hypersensitivity
pneumonitis and stop methotrexate
D. Give a high-dose oral pulse of steroid
and increase methotrexate for
rheumatoid lung
53. DMARDs Have a Dark Side
Don’t Miss It
DMARDs have a dark side
Methotrexate may cause
serious problems
Lung
Liver
Bone marrow
Be on the look out for toxicity
with all the DMARDs
54. Methotrexate Lung
• Dry cough, shortness of breath, fever
• Most often seen in the first 6 months of MTX
treatment
• Diffuse interstitial pattern on x-ray
• Bronchoalveolar lavage may be needed to rule
out infection
• Acute mortality = 17%; 50% to 60% recur with
retreatment, which carries the same mortality
• Risk factors: older age, RA lung, prior use of
DMARD, low albumin, diabetes
Kremer, et al. Arth Rheum. 1997;40:1829–1837.
55. Rheumatoid Arthritis: Summary
• Joint damage begins early
• Effective treatment should begin early in most
patients
• Aggressive treatment can make a difference
• Assess severity of patient’s disease
• Current activity
• Damage
• Pace
56. Rheumatoid Arthritis: Summary (cont’d)
• Choose a treatment plan with enough power to
match the disease
• If in doubt, get some help
• Rheumatologists can be a bargain
• New classes of drugs and biologics offer new
opportunities
• Do no harm
• Monitor for drug toxicity—high index of
suspicion and routine monitoring
• Alter the treatment based on changes in
disease activity