RHEUMATOID ARTHRITIS AND MEDICATION
Musculoskeletal and rheumatic complaints account for approximately 15% of the patients seen by primary care physicians. These complaints include muscle pain and weakness, regional pain syndrome such as back or neck pain, rheumatoid arthritis, gout, ankylosing spondylitis and lupus erythematosus among others. Rheumatologists are specialists in the diagnosis and management of musculoskeletal disorders having completed three years of training in the broad field of internal medicine and a two year fellowship in rheumatology.
Rheumatoid arthritis is a systemic disorder characterized by female predominance. It is persistent, symmetric and may be associated with systemic features such as fatigue, weight loss and anemia. 70 - 80% of patients with rheumatoid arthritis are positive with rheumatoid factor (an antibody against IgM). Most patients also have an elevated sedimentation rate.
Medications are useful in managing inflammation associated with rheumatoid arthritis. The first compounds employed are either salicylates or other nonsteroidal anti-inflammatory drugs. These medications exert their anti-inflammatory action by modifying prostaglandin metabolism. They are used as initial therapies. All share common toxicities including stomach upset, liver function abnormality, renal dysfunction and fluid retention. About 1 - 2% of people who take aspirin or other nonsteroidal anti-inflammatory drugs may have peptic ulceration.
In those patients who cannot be managed with aspirin or other nonsteroidal anti-inflammatory drugs, medications such as golden injections, Plaquenil, penicillamine and Methotrexate are employed in an attempt to modify the course of the disease.
Gold is a remittive agent that can prevent disease progression. It is generally given by injection but can be taken orally. It has some common toxicities including skin and mucous membrane problems. About 1% of patients get kidney or blood problems related to gold injections and/or oral ingestion.
Careful monitoring of gold therapy is very important in patients with rheumatoid arthritis. During the duration of the therapy complete blood counts, platelet counts and urinalyses must be done at the time of each injection. After a prolonged period of time without toxicity monitoring may be done every other injection. If severe blood reactions and/or kidney problems develop then medication should be discontinued.
Plaquenil or hydroxychloroquine is an anti-malarial agent with anti-inflammatory properties in rheumatoid arthritis. Like gold it is used in those patients who fail to respond to a conservative regimen including rest, salicylates and/or other nonsteroidal anti-inflammatory drugs. These are given orally. Ophthalmologic monitoring is necessary to check for visual loss at an early reversible stage. Patients should be seen by their eye doctors a minimum of once a year. This therapy should be discontinued if any eye problems are related to the medication.
Penicillamine has been shown in controlled studies to be effective in reducing inflammatory arthritis such as rheumatoid arthritis. It is given orally. Like gold it may be associated with a variety of problems including skin and mucous membrane problems, blood disorders and/or kidney problems. It must be carefully monitored. Complete blood counts, platelet counts and urinalyses should be done monthly for the first six months of therapy and every other month thereafter. Laboratory data is essential to permit early detection of problems with the blood and/or kidneys.
Corticosteroids are among the most potent of the anti-inflammatory agents. However they have a high incidence of toxicity and may not change the course of rheumatoid arthritis. They should only be used in patients with activie synovitis in many joints. These medications are useful in incapacitating constitutional symptoms such as fever, anemia, wieght loss, neuropathy and vasculitis (blood vessel inflammation).
Prednisone is the preferred agent because of its cost and low potential for fluid retention. Tablets are available in 1 mg and 5 mg dosages. All patients should be educated about the side effects of corticosteroids. Informed consent is most inportant in their use.
Methotrexate is a new usage of a very old medication. In general it is given by "modified pulse" with 3 to 9 tablets administered weekly. Methotrexate should only be given by those physicians who are knowledgeable and experienced in its usage. The use of Methotrexate involves periodic monitoring for toxicity. Monitoring should include complete blood counts with differential and platelet counts. It should also involve liver and renal function tests. Patients who are at increased risk for impaired Methotrexate elimination (i.e., patients with kidney problems) should be monitored more frequently.
Methotrexate may be associated with a variety of problems including liver toxicity, lung problems, mouth ulcers, stomach pain, etc. Liver biopsies may be necessary if there is a question about the degree of Methotrexate liver toxicity and continuation of this drug.
Rheumatoid arthritis is a manageable disorder is patients who are treated by rheumatologists and/or experienced internal medicine physicians. With proper education, exercise and medications many patients may expect to lead fairly normal lives. The goals of treatment are to maintain joint function and to prevent deformity. Medications are available for this purpose. However, they must be used by physicians who are knowledgeable about their use and employ the proper monitoring techniques.
Physicians who use these medications in patients with rheumatoid arthritis must be aware of the strong possibility of serious side effects. All the ramifications of treatment should be duscussed with the patient prior to initiation of these medications. Patients using these medications should be under constant physician supervision.