There are a large number of NSAIDs from which to choose, and at full dosages all are potentially equally effective. Prostaglandins are mediators of inflammation and pain but also have important roles in maintenance of normal body functions including protection from stomach acid, maintenance of kidney blood flow, and contributing to platelet stickiness and vascular function.
COX-2 selective inhibitors selectively block prostaglandins generated via COX-2 which have prominent roles in inflammation. While in some cases, lower doses of NSAIDS are effective, in rheumatoid arthritis and other forms of inflammatory arthritis a higher dose is often required to decrease inflammation. A lower dosage can initially be used if inflammation is mild, if mechanical pain is the major problem, if the patient is elderly or if the patient suffers from conditions that increase the risk for toxicity see below.
If a particular preparation is ineffective after a 4-week trial or is not tolerated, then another NSAID can be initiated.
Although these agents have anti-inflammatory effect within hours, a reasonable trial period is a few weeks to 1 month. The most common toxicity of NSAIDs is gastrointestinal disturbance which may clinically include burning, belching, or irritation, but which can represent irritation of the lining of the stomach, erosions, and even ulcerations that can result in bleeding. While taking the medication with food may eliminate some of these symptoms, this does not decrease a risk of bleeding.
Because prostaglandins play a role in the regulation of the blood flow in the kidneys and maintenance of glomerular filtration, NSAIDs can also impair renal function in certain patients leading to salt retention, edema, and increased blood pressure. The patients at highest risk are those with fluid imbalances or with compromised kidney function e. NSAIDs may also increase cardiovascular risks by their effects on blood pressure and additional effects on vascular beds.
Thus the use of this class of medications must into account their relative risks in an individual patient of gastrointestinal damage versus potential cardiovascular risk factors. They can be given orally, intravenously, intramuscularly or can be injected directly into the joint. Corticosteroids are useful in early disease as temporary adjunctive therapy while waiting for DMARDs to exert their antiinflammatory effects.
The usual dose of predinisone is 5 to 10mg daily. Although prednisone can be started at higher doses 15 to 20mg daily , attempts should be made to taper the dose over a few weeks to less than 10mg daily. Once started, corticosteroid therapy may be difficult to discontinue and even at low doses. Some patients are very sensitive to the tapering of prednisone which may be done slowly over a few weeks. Other side effects of prednisone include weight gain, increased blood pressure, increased blood sugar, increased risk of cataracts, and avascular necrosis of bones.
Steroid medications are also associated with accelerated osteoporosis even with relatively low dose prednisone at doses of 10 mg daily. Patients with and without osteoporosis risk factors on low dose prednisone should undergo bone densitometry DEXA Scan to assess fracture risk. Higher doses of prednisone are rarely necessary unless there is a life-threatening complication of RA and, if used for prolonged periods, may lead to serious steroid toxicity. Although a few patients can tolerate every other day dosing of corticosteroids which may reduce side effects, most require corticosteroids daily to avoid symptoms.
Once a day dosing of prednisone is associated with fewer side effects than the equivalent dose given twice or three times daily.
Repetitive short courses of high-dose corticosteroids, intermittent intramuscular injections, adrenocorticotropic hormone injections, and the use of corticosteroids as the sole therapeutic agent are all to be avoided. Intra-articular corticosteroids e.
DMARDs have an effect upon rheumatoid arthritis that is different and may be slower. In most cases, when the diagnosis of rheumatoid arthritis is confirmed, DMARD agents should be started. The presence of erosions or joint space narrowing on x-rays of the involved joints is a clear indication for DMARD therapy, however one should not wait for x-ray changes to occur.
The currently available drugs include:. It has a relatively rapid onset of action at therapeutic doses weeks , good efficacy, favorable toxicity profile, ease of administration, and relatively low cost.
When looking at groups of patients on different DMARDS, the majority of patients continue to take Methotrexate after 5 years, far more than other therapies reflecting both its efficacy and tolerability. Methotrexate is effective in reducing the signs and symptoms of RA, as well as slowing or halting radiographic damage. It was as effective as leflunomide and sulfasalazine in one study, and its effectiveness given early and in higher doses approached the efficacy of etanercept and adalimumab as single therapies in terms of signs and symptom improvement.
Methotrexate is also effective in many other forms of inflammatory arthritis including psoriatic arthritis and other spondyloarthopathies, and is used in many other autoimmune diseases.
The anti-inflammatory effects of methotrexate in rheumatoid arthritis appear to be related at least in part to interruption of adenosine and possible effects on other inflammatory and immunoregulatory pathways. The immunosuppressive and toxic effects of methotrexate are due to the inhibition of an enzyme involved in the metabolism of folic acid, dihydrofolate reductase.
Dosing typically begins at A dose escalation to 20 mg within the first three months is now fairly well accepted in clinical practice. Maximal dose is usually 25 mg per week but is sometimes increased further to 30 mg.
Methotrexate can be given orally or by subcutaneous injection. The latter route of administration can be advantageous for patients who have methotrexate-associated nausea. Patients starting methotrexate should be carefully evaluated for renal insufficiency, acute or chronic liver disease, significant alcohol intake or alcohol abuse, leukopenia low white blood cell counts , thrombocytopenia low platelet counts , or untreated folate deficiency.
Obesity, diabetes and history of hepatitis B or C are factors that have been suggested but not confirmed to increase methotrexate hepatotoxicity liver injury. If alternatives exist, concomitant use of methotrexate and trimethoprim is to be avoided.
The coadministration of NSAIDS with methotrexate is routine in patients with rheumatoid arthritis and is considered safe by rheumatologists as long as liver function tests and blood counts are closely monitored. The onset of action is seen in as early as 4 to 6 weeks. However the dose required to achieve a response is variable in individual patients and may require weeks after a dose increase to determine if the drug is working.
A trial of 3 to 6 months at an increased dose e. In patients with partial responses to methotrexate, additional medications are usually added to rather than substituted for methotrexate to achieve combination therapies. Fortunately the most serious complications of methotrexate therapy: hepatic cirrhosis, interstitial pneumonitis, and severe myelosuppression are quite rare, especially with proper monitoring.
Stomatitis and oral ulcers, mild alopecia and hair thinning, and GI upset may occur and are related to folic acid antagonism. These side effects can be improved with folic acid supplementation. Folic acid given at a dose of 1mg daily does not diminish the efficacy of methotrexate and is routinely given with methotrexate to decrease these side effects.
Some patients complain of GI upset nausea or diarrhea with oral methotrexate. This may be lessened when methotrexate is taken at night. In most cases this is completely eliminated when methotrexate is given by subcutaneous administration. Before starting methotrexate, baseline studies should include complete blood count, liver chemistries, serum creatinine, hepatitis B and C serologies, and chest X-ray.
Routine toxicity monitoring should include a CBC, liver profile, serum albumin and serum creatinine every weeks. In all clinical trials combining methotrexate with one of these DMARDs, no unexpected toxicities or synergistic toxicities were observed with the exception of higher liver toxicity with leflunomide which is also metabolized by the liver. Hepatotoxicity liver injury has not been significant if patients with pre-existing liver disease, alcohol abuse, or hepatic dysfunction are excluded from treatment with methotrexate.
Patients are instructed to limit alcohol containing beverages to no more than one-two per week. Baseline or surveillance liver biopsies are not indicated unless pre-existing liver disease is suspected. Elevated liver enzymes do not directly correlate with toxicity but therapy should be stopped and doses of methotrexate reduced if transaminases are elevated to 2 times the upper limit of normal.
Liver biopsy should be done if elevated liver enzymes persist or if methotrexate therapy is to be continued. Methotrexate pneumonitis may occur at any time during therapy and is not dose related. A baseline chest x-ray is useful for comparison. Patients with poor pulmonary reserve from other causes may be excluded from therapy over concerns of increased morbidity if methotrexate pneumonitis occurs.
A more chronic form of interstitial lung disease and fibrosis is also seen in patients with rheumatoid arthritis. This may be increased with methotrexate. Myelosuppression lowering of blood counts is also rare at the low doses of methotrexate utilized for rheumatoid arthritis.
In the absence of leukopenia lowered white blood cell counts , there has not been conclusive information to link methotrexate use in rheumatoid arthritis with increased risk of infection. The exception is a slight increased risk of localized herpes zoster infection shingles. Cancer risk with methotrexate. Although there are case reports of lymphoma associated with methotrexate therapy including cases where the lymphoma resolved after cessation of therapy, increased occurrence of malignancy has not been found in large population-based studies.
It is important to recognize that patient with rheumatoid arthritis have an increased risk of developing lymphoma as a consequence of their autoimmune disease, independently from any potential medication effects.
Pregnancy and Conception with methotrexate. There have not been any notable effects on sperm production or ovarian function after the prolonged administration of methotrexate.
This may help to reduce stiffness. Certain devices such as splints and braces can hold your joints in a resting position. This may help to reduce inflammation. Canes and crutches can help you maintain mobility, even during flares.
You can also install household devices, such as grab bars and handrails in bathrooms and along staircases. Learn more about these and other remedies to help you manage life with RA.
Your healthcare provider or dietitian may recommend an anti-inflammatory diet to help with your symptoms. This type of diet includes foods that have lots of omega-3 fatty acids. Foods high in omega-3 fatty acids include:. Antioxidants, such as vitamins A , C , and E , and selenium , may also help reduce inflammation. Foods high in antioxidants include:. Eating lots of fiber is also important.
According to some researchers, fiber may help reduce inflammatory responses which may decrease C-reactive protein levels. Choose whole grain foods, fresh vegetables, and fresh fruit. Strawberries may be particularly beneficial.
Foods containing flavonoids can also help to counter inflammation in the body. They include:. Make sure to avoid trigger foods. These include processed carbohydrates and saturated or trans fats. Avoiding trigger foods and choosing the right foods in trying to follow an anti-inflammatory diet may help you manage your RA. There are several different types of RA.
Knowing which type you have may help your healthcare provider provide the best type of treatment for you. Get more details on the types of RA and their differences. Seropositive RA is the most common type of RA. This type of arthritis may run in families. Seropositive RA may come with more severe symptoms than seronegative RA.
Some people with seropositive RA can experience inflammation in the eyes, salivary glands, nerves, kidneys, lungs, heart, skin, and blood vessels. However, certain factors seem to play a role in increasing the risk of developing RA or triggering its onset.
The cause may not be known but there are several risks and triggers. Arthritis in the hands may start as a low-level burning sensation that you feel at the end of the day. If the cartilage in your joints wears away, you may notice some deformities in your hands. You may also have a grinding feeling in the joints of your hands, fingers, and large joints, if the cartilage deteriorates completely.
As the disease progresses, fluid-filled sacs or synovial cysts typically develop in the wrists, knees, elbows, ankles and around the small joints of the hands. You may also develop knobby growths, called bone spurs, in the affected joints. Over time, bone spurs can make it harder for you to use your hands. If you have RA in your hands, your healthcare provider will work with you on exercises that can help you retain movement and function.
Exercises, along with other types of treatment, can help reduce inflammation and stave off progression of the disease. Currently this program is for the adult arthritis community. Since the needs of the juvenile arthritis JA community are unique, we are currently working with experts to develop a customized experience for JA families. Get Started. As a partner, you will help the Arthritis Foundation provide life-changing resources, science, advocacy and community connections for people with arthritis, the nations leading cause of disability.
Join us today and help lead the way as a Champion of Yes. Our Trailblazers are committed partners ready to lead the way, take action and fight for everyday victories.
Our Visionary partners help us plan for a future that includes a cure for arthritis. Our Pioneers are always ready to explore and find new weapons in the fight against arthritis. Our Pacesetters ensure that we can chart the course for a cure for those who live with arthritis.
Our Signature partners make their mark by helping us identify new and meaningful resources for people with arthritis. Our Supporting partners are active champions who provide encouragement and assistance to the arthritis community. Rheumatoid Arthritis: Causes, Symptoms, Treatments and More This inflammatory form of arthritis causes joint pain, swelling and damage. Updated Oct, 15, Rheumatoid arthritis RA causes joint inflammation and pain. These symptoms are clues to RA: Joint pain , tenderness, swelling or stiffness that lasts for six weeks or longer.
Morning stiffness that lasts for 30 minutes or longer. More than one joint is affected. Small joints wrists, certain joints in the hands and feet are typically affected first. The same joints on both sides of the body are affected. Dryness, pain, inflammation, redness, sensitivity to light and trouble seeing properly.
Dryness and gum inflammation, irritation or infection. Rheumatoid nodules — small lumps under the skin over bony areas. Inflammation and scarring that can lead to shortness of breath and lung disease. Blood vessels. Inflammation of blood vessels that can lead to damage in the nerves, skin and other organs. A lower than normal number of red blood cells. Inflammation can damage the heart muscle and the surrounding areas.
Painful joints also make it hard to exercise , leading to weight gain. Being overweight may make people with RA more likely to develop high cholesterol, diabetes, heart disease and high blood pressure. Rheumatoid factor RF is an antibody found eventually in about 80 percent of people with RA. However, they are also found in people without RA. The goals of RA treatment are to: Stop inflammation or reduce it to the lowest possible level put disease in remission.
Relieve symptoms. Prevent joint and organ damage. About half of all people with rheumatoid arthritis have rheumatoid factor in their blood when the condition starts.
However, around 1 in every 20 people without rheumatoid arthritis also test positive for rheumatoid factor. There is another antibody test called anti-CCP that you can take.
People who test positive for anti-CCP are very likely to get rheumatoid arthritis. However, not everyone that has the condition has this antibody. Scans may be used to check for joint inflammation and damage. These can be used to diagnose rheumatoid arthritis and to check how the condition is developing. There are a variety of treatments available for rheumatoid arthritis. The earlier that intensive treatment is started, the more likely it is to work. Many people with rheumatoid arthritis need to take more than one drug.
This is because different drugs work in different ways. Your drug treatments may be changed from time to time. This can depend on how bad your symptoms are, or because something relating to your condition has changed. Drugs may be available under several different names. Each drug has an approved name — sometimes called a generic name. Manufacturers often give their own brand or trade name to the drug as well. For example, Nurofen is a brand name for ibuprofen. Painkillers can help to relieve the pain caused by rheumatoid arthritis, but should not be the only treatment used.
There are many types and strengths of painkillers available — some can be bought over the counter from a pharmacy, while some are only available on prescription. It is important to keep taking your medication during this time.
For more information on the types of drugs used to treat rheumatoid arthritis, see our drugs content. Corticosteroids help to reduce the pain, stiffness and inflammation caused by rheumatoid arthritis. They're usually used to provide short-term pain relief. Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, including weight gain, osteoporosis and thinning of the skin.
It can be dangerous to stop steroids suddenly. NSAIDs can be used to help control symptoms of pain, swelling or stiffness. They can be used in combination with painkillers. When your symptoms get worse, this is known as a flare-up. These can happen at any time, but can happen after you have been stressed or had an infection. It may be that you need to review your treatment. Heated items that could help your joint pain include a hot water bottle or electric heat pad.
Wrap these in a towel, then place on a painful joint. You could also try having a hot or warm shower or bath. Other heated items that people have found useful are wheat bag, heat pads, deep heat cream, or a heat lamp. Make sure these items are warm but not hot, as you could risk burning or scalding yourself. Gentle heat will be enough. A towel should be placed between the heated item and the skin for protection. Check your skin regularly, to make sure it is not burning.
Some people find that using an ice pack can help their joint pain. You can buy one from a pharmacy, or you can make one at home, by wrapping ice cubes in a plastic bag or wet tea towel. You may find it difficult to be physically active in the first place, especially if you are having a flare-up. However, if you find the right activities, help and support, you can be active in a way that suits you.
Not keeping active can lead to stiff joints and weak muscles. It could also cause you to gain weight. As you get used to it, this will get better. However, if a type of exercise always causes a flare-up, it's probably best to find another one. High-impact exercises such as step exercises, or contact sports, such as rugby and football, are more likely to cause problems. Swimming, walking, gentle cycling and aqua aerobics generally put less strain on your joints. Yoga and tai chi are generally thought to be suitable for those with rheumatoid arthritis.
However, there are many different styles, so it is best to check the style is suitable for your condition before you sign up to a class. You should also break up long periods of sitting with light activity, to avoid being sedentary for extended periods. A physiotherapist can suggest suitable exercises for you and support you in keeping active.
People with rheumatoid arthritis should have access to specialist physiotherapy to help manage their condition and improve their fitness, flexibility and strength.
You should also have follow-up reviews. Find a physiotherapist on The Chartered Society of Physiotherapy website. You may also find that hydrotherapy helps to ease your symptoms. This involves doing special exercises in a warm-water pool, under the supervision of a trained physiotherapist. Any member of your healthcare team should be able to refer you to an NHS physiotherapist if they think you might benefit from hydrotherapy.
In some parts of the UK, you can also refer yourself to a physiotherapist , who will assess whether hydrotherapy would be suitable for you. Check with your GP or call your local rheumatology department to find out if an NHS physiotherapist in your area will accept self-referrals.
It can help to improve the pain in your joints, and you may also find it relaxing. Ask your doctor or physiotherapist if they think hydrotherapy would be suitable for you. If these problems are left untreated, they can lead to the infections spreading and, eventually, to ulcers forming. It is therefore important to see a podiatrist , who specialises in general foot care.
They can give advice on footwear, information on how to treat foot problems yourself, and can provide special insoles. They can also monitor your foot and general health, and will refer you to a consultant if they find any issues.
There may be a podiatrist in the rheumatology department where you receive your care, or you may get a referral to an NHS podiatrist.
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