Useful laboratory tests for patients with recent onset inflammatory polyarthritis may include complete blood count,
erythrocyte sedimentation rate, rheumatoid factor test, aspartate aminotransferase (AST) test, creatinine level and urinalysis.
Erythrocyte sedimentation rate is an inexpensive measure of disease activity in those with rheumatoid arthritis; however,
the test is not diagnostic and rates are not elevated in all patients affected. A positive test result for rheumatoid factor
is helpful but not essential to confirm the clinical impression of rheumatoid arthritis in the setting of symmetrical inflammatory
polyarthritis. If the arthritis has lasted more than a year, the physician should consider taking radiographs of the hands
and feet.
The importance of diagnosing rheumatoid arthritis cannot be overemphasized - early intervention with DMARDs has been
shown to improve long-term outcomes,and once joint damage has occurred erosion and joint instability are irreversible. If
rheumatoid arthritis is mild and in its early stages many rheumatologists favour using hydroxychloroquine because it is safe
and convenient. If control is suboptimal after 6 months, additional DMARDs are often prescribed. A recent study reported some
efficacy with minocycline for patients with early seropositive rheumatoid arthritis. However, long-term efficacy data for
patients treated with minocycline are not available, and radiographs show that damage progresses at the same rate as in placebo-treated
patients.
If a patient has moderate or severe rheumatoid arthritis, especially if the rheumatoid factor is positive, injectable
gold or methotrexate may be the preferred DMARD. Gold treatment has the important advantage of offering the potential for
disease remission, but methotrexate is more convenient and better tolerated. Sulfasalazine is safe as a second-line agent
and can be used in combination with methotrexate and other DMARDs. Many new DMARDs are becoming available.
There is frequently a delay between the presentation of polyarthritis and the confirmed diagnosis, and there is always
a delay before a prescribed DMARD has the expected benefit. When optimal DMARD therapy or a combination of DMARDs does not
control synovitis, low-dose prednisone can provide symptom relief, acceptable low toxicity and joint protection. Bisphosphonate,
either cyclical tidronate or daily alendronate, reduces the risk of steroid-induced osteoporosis and should be prescribed
prophylactically when the daily dose of prednisone is 7.5 mg or more.
Patients with active rheumatoid arthritis should be assessed by a rheumatologist on a regular basis, and clinical and
laboratory evaluations should be repeated to measure the efficacy and toxicity of treatment. The aim of therapy is to minimize
pain, stiffness and joint swelling; retard joint damage; and reduce future disability.
In patients who are under 50 years of age with joint pain and swelling lasting longer than 6-8 weeks the diagnoses to
be considered include rheumatoid arthritis, psoriatic arthritis, other seronegative spondyloarthropathies and SLE. In patients
over 50 years of age,crystal-induced synovitis should also be considered. Osteoarthritis may also cause considerable inflammation
in the affected joints. For most of these conditions specific therapies aimed at controlling inflammation, preserving range
of motion in the joint and preventing joint damage are successful in decreasing morbidity and improving quality of life.
The patient with symptoms in many joints requires a detailed history and physical examination. If there is morning stiffness
lasting more than 30 minutes or stiffness after sitting, the joint complaints are likely to be caused by inflammation; a convincing
history of joint swelling confirms the presence of inflammation . The physician should record the onset and progression of
symptoms and the distribution of joints affected.
A history of psoriasis in the patient or a family member is an important clue to the possibility of psoriatic arthritis.
The physician should also inquire about a history of iritis or inflammatory bowel disease, both of which are associated with
seronegative spondyloarthropathies.
A recent episode of infectious diarrhea or genitourinary infection are clues to possible Reiter's syndrome. Does
the patient have symptoms suggestive of SLE (e.g., photosensitive or malar rash, alopecia or pleurisy)? Is there a past history
of acute episodes of arthritis or gout? Are the joints tender or swollen? Is movement limited? The choice of laboratory tests
that may help depend on the differential diagnosis.
Patients must be made aware of the need for monitoring. The incidence of serious side effects is markedly reduced with
regular monitoring, because adverse effects are more likely to be discovered before serious or irreversible consequences arise.
Despite the long list of side effects, which often intimidates patients, long-term series of rheumatoid arthritis patients
treated with DMARDs have found that serious side effects are rare.
When counselling a patient who expresses concern about potential side effects, it is also important to remind him or
her of the consequences of the alternative; doing nothing will result in irreversible disability, progressive joint damage
and premature death. It is also important to recognize that information on the use of antirheumatic drugs in other fields
of medicine may not be applicable to patients with rheumatic diseases. Drugs such as methotrexate and cyclosporine, which
are used in cancer therapy and transplant programs respectively, are used in lower doses for rheumatoid arthritis, and the
incidence of adverse events is lower.
Persistence in the use of DMARDs is of great importance. DMARDs are used to treat incurable, chronic diseases where treatment
will be lifelong and the number of available options is limited.
Typically a patient with rheumatoid arthritis will use a succession of DMARDs over the years. After an initial response,
a drug is often eventually discontinued, either because of adverse side effects or loss of effect. To ensure the best result,
it is important to give each drug a full trial, namely, the maximum dose for sufficient time, before declaring it not efficacious.
In addition, there are a number of strategies for dealing with common side effects. Rather than stopping treatment, the patient
may be referred to a rheumatologist, or one can be consulted by the physician, regarding the management of persistent side
effects.
The use of a combination of DMARDs is now widely practised. Some rheumatologists advocate the use of combination therapy
from the onset of disease for early control, with a subsequent gradual withdrawal of therapy, as necessary to maintain control.
Others prefer the opposite strategy: successively adding DMARDs to agents to which the patient has shown a partial response.
Proponents of the latter view believe it prevents unnecessary exposure to potentially toxic drugs of patients who may respond
to single therapy. This approach may also be more acceptable to patients.
Commonly used combinations include hydroxychloroquine with most DMARDs, especially methotrexate or intramuscular
gold; sulfasalazine and methotrexate with or without hydroxychloroquine; and cyclosporine and methotrexate.
The treatment of early rheumatoid arthritis is now recognized as crucial to long-term outcome, and the selection
of agents is a complex task owing to the rapidly increasing number of treatments available, alone or in combination. When
possible, a rheumatologist should be involved in this decision-making process.
There is no consensus as to the order in which DMARDs should be chosen for the treatment of rheumatoid arthritis or other
inflammatory arthritides. Choice must be tailored to the patient's profile and preference, disease activity and prognostic
markers of disease severity.
The use of corticosteroids results in rapid, potent and reliable suppression of inflammation. This explains their wide
use for the inflammatory manifestations of rheumatic diseases and for systemic vasculitis. However, their effect in suppressing
the synovitis in rheumatoid arthritis is not sustained and requires a progressive increase in dosage to maintain the benefit.
The precise role of orally administered corticosteroids in rheumatoid arthritis remains controversial. Short courses
of low-dose steroids can be useful as "bridging therapy" to control symptoms while waiting for DMARDs to take effect or to
control severe flare-ups. Patients can decrease the dose as soon as symptoms are under control. The injection of steroids
into the most affected joints can often alleviate the need for oral steroids (at the rate of 1-2 large joints every 2-6 weeks).
Intramuscular injections of corticosteroids are advocated by some to prevent difficulties in tapering off the dose of oral
corticosteroids.
The use of an alternate-day regimen is associated with a lower incidence of some of the side effects Maintenance
of control of the disease can be a problem. Switching from daily to an alternate-day regimen must be done gradually (by tapering
off the dose on alternate days down to zero) to prevent both adrenal insufficiency and exacerbation of the disease. Administration
of the dose in the evening, a divided dose and the use of longer acting forms are associated with greater adrenal suppression.
It is useful to think of corticosteroid administration in 3 broad ranges: low dose (i.e., the equivalent of orally administered
prednisone, 15 mg daily or less), as used in the treatment of polymyalgia rheumatica, active arthritis and mildly active systemic
lupus erythematosus; moderate dose (i.e., 15-25 mg daily); and high dose (i.e., 25-60 mg daily), as used in the treatment
of acute manifestations of systemic vasculitis and the more severe manifestations of systemic lupus erythematosus.
Unfortunately,RA has the reputation that it is incurable-that nothing can be done. RA is currently incurable,it certainly
is treatable-at any stage-early the easier,and better. Health care systems are changing. The old system wherein physicians
made all the decisions is slowly disappearing. In the new system, patients,especially those with complex diseases,can be misunderstood,
The choice and the responsibilities,are yours. It is your health,and no one else will pay as much attention to it,or will
benefit from it as much as you.
If you have rheumatoid arthritis,you need to be proactive. You have to initiate contact with your health care providers
and get along with them. The right diagnosis is the start. You will most certainly require the services of a rheumatologist
for treatment and monitoring of your disease. Most of all you need to become more educated about your disease The most important
thing in management of the disease is to get it under control.
If the inflammation associated with RA is controlled,most of the other problems that occur as a result of the devastating
effects of inflammation is gone or minimized. Don't accept you have to live with it,(always) you may have to live with it
up to a certain point.but understand your treatment options and never accept treatments just because someone said it may work.
They may not work for you.
Most RA patients get lost in a maze of treatmentment options (and unfounded opinions),valuable time and the opportunity
to control the disease is lost.
It is your life and your disease. Make the decision to get the treatment you need to get your disease under contol,and
forget Uncle Jims's arthritis symptoms and treatment,or your friend's back problem treatments. The first step,is seeing a
rheumatologist. Family doctor's are one of the most valuable people in this world,but a good doctor who have your sole interests
will refer you to one.
The family doctor's training in rheumatology is a very,very low time (estimated at less than 1 %-if the option in taken)spent
in rheumatology,and furthermore some do not take the rheumatology option offered at medical school. My family doctor admits
it,and quickly refers when he is not quite sure. of any complex problems of the human body,that what he is trained to do.
A most valuable physician,we can not afford to be without,but with limitations in regard to certain problems that may arise.