Sock's Treatment And Management Of Rheumatoid Arthritis Pages
Summary
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Approximately 15 % of cases will be come on suddenly,over a matter of days. Although not all the joints that will eventually cause trouble will be involved in this first attack,there may be two dozen,which is typical. They will include the MCPs and MTPs. Similar joints on both right and left sides will be involved. Morning stiffness and fatigue will be prominant.
 
About 75 % of the time the scenery is less spectacular. A wrist becomes swollen and for some time it's the only problem. Or a patient develops marked tenderness under the balls of both feet (MTP joints),particularily when first getting out of bed. Gradually,over several weeks to several months,more and more joints show up. Fatigue and morning stiffness also come into play. It may take a year or so before the pictire is clear enough for  definite diagnosis.
 
In 10 % of cases,-A single joint such as the knee,wrist or shoulder,suddenly becomes very painful,swollen and warm. Often the pain is so severe that the joint can't be used. Two or three days later,it's back to normal. After a month or so another attack strikes,usually in another joint. With time,the attacks becomes more frequent. Gradually they are less and less severe but more and more frequent,and instead of clearing up,the pain starts to persist. One day, perhaps after a year more it becomes obvious that the problem is RA. This pattern is called palindromic rheumatism,and while it doesn't always turn out to be RA,it most often does.
 
Palindromic rheumatism may clear up as mysteriously as it comes on,may continue indefinitely,or may evolve into very active rheumatoid arthritis, requiring aggressive action.
 
Very rarely,RA first appears in an extra-articular (EAFs-non-joint) site,with joint symptoms appearing months later. When it does,it usualy  takes the form of chest complications,and the patient is usually male.
 
The inflammation associated with RA also occurs outside the joints. Extra-articular features are more common in patients with moderate and severe disease,but they can occur in mild cases too. Since RA can cause EAF's,it can be viewed as a disease that affects the whole body and not just the joints. the most common EAf in RA is tendonitis or tenosynovitis. Tenosynovitis is inflammation of the tendon sheath.
 
Rheumatoid nodules (usually over pressure points may appear,it is associated with the moderate-severe type of RA.but it not limited to type. The heart may become involved in RA. (Pericardium-pericarditis-detected with simple ultra sound tests) Lungs-inflammation of lungs is comon. The nervous sstem can be affected-the most common is carpel tunnel syndrome (CTS). RA can also affect nerves in other parts of the body. In rare cases,RA can be so wide-spread that it causes withinin the linings of blood vessels. Eyes can be affected. These features are discussed in other section of my sites in more detail.
 
"There are mild,moderate and severe types of RA (type is more in reference to severity of disease). The effects,medication,day-to-day living and prognosis will be individually different in each case.
 
Being diagnosed with RA is one thing,but living individually is another thing."
 
Thirty percent of patients have the mild type of RA. Thirty to forty percent have the moderate form. Approximately ten percent will have the severe  manifestations of RA to confront. Severe means severe. Ten to fifteen percent of all patients have the type of arthritis characterized by stiffness. This type leads to abnormal tightness than to swelling in the small joints f the hands,wrist,shoulders,and occassionallythe knees and feet The stiffness is marked In this type the joints may look normal,but the patient may find it difficult to hold a glass of water in their hands.Loss of function is the major problem caused by this stiffness.
 
The need of a rheumatologist is clearly,required for a successful conclusion. Due to the medical training system currently taught,family doctor are given less than 1 % of rheumatology training at medical school. They have a option to take this limited option in rheumatology and many family physicians and internists choose not to take this available option.
 
Rheumatologists are trained in feeling the normally microscopic synovial membrane lining (which becomes thick in RA) they are trained in "bone count" (number of tender joints). Family doctors and most internists are not trained at medical school in this,and other necessary procedures required in rheumatology. The number of rheumatic diseases makes it impossible for a general practice or internist to follow,in depth.. It is a matter of common sense and factual.
 
Experience and knowledge is provided by a rheumatologist. The family doctor is invaluable,they take care of our general health,and a good doctor,will refer the patient to a specialist.
 
People have to take repossession of their lives. One of the simplest isn't always easy,but it's effective. Relax,pain,causes stress and tension,and not just psychological tension. Taking a relaxation training session teaches you to enter a more relax physical state that lowers blood pressure,respiratory rate,and adrenalin flow.
 
You'll be taught to lie down and find a comfortable breathing rhythm. Close your eyes,focus on your body's different muscle groups,starting with your calf muscles. Slowly relax your muscles,moving progressively up your body to your neck and shoulders. As the muscles relax,there's a cocomitant release of the body's natural opiates (endorphins),pain relieving hormone's that are related to synthenic opiates like morphine.
 
Endorphins can be released by any number of stimuli,including laughter. A good belly laugh relaxes stomach muscles,and that may be one reason why it works,releasing muscle tension is a relief fron an unconscious source of pain and discomfort. The heart speeds up,blood pressure rises and,when respiration accelerates,there's an increase in oxygen exchange. A good belly laugh when watching a TV sitcom not only exercises your diaphragm and abdomen,but the muscles of your face and shoulders and sometimes even the muscles of your legs and arms.
 
By the time your laughter subsides at the commercial break,you've had a short aerobic workout. After an  exhausting "laugh-out",don't underestimate the value of rest,energy conservation,and sleep.

Combination Therapy:
 
Some promising combinations include: 1) methotrexate (mtx) and sulfasalazine (ssz) and hydroxychloroquine. 2) mtx and intramuscular gold . 3) mtx and etanercept. 4) mtx and leflunomide 5) mtx and infliximab. 6) mtx and cyclosporin has been tried ,but due to higher toxicity of cyclosporin it is not used commonly,today.  7) mtx and arava might not work for everyone. Monitoring and selection will  vary due to differences in patient efficacy.
 
Methotrexate has become the gold standard in North America. It promises early onset of action,usually within 4 to 6 weeks. MTX is usually given as tablets,but can be given subcutaneously. The effective weekly dose for a patient may be low as two 2.5 mg tablets,or as high as ten. The averag is % tavlets (12.5mg.) once a week. Because the effective dose range is so wide,its best to start low (3 tablets / week). and only slowly increase the dose by one tablet each time. changes in dose should occur no more often than every 3 weeks;once a month is the usual.
 
It is unusual to notice a good response at a fairly low dose at first,but then to require a higher dose later on to maintain that response. a complete blood count (hemoglobin,white cell and platelet counts ) is usually done every 2 weeks until the final dose is selected,then every 4 to 6 weeks Liver function test may be performed,depending on the patient situation. Some patients claim better response with the injection procedure with less side effects.
 
NSAIDs don't interact with MTX when MTX is taken in the doses recommmended; however,sulfa-containg antibiotics increase the risk of side effects and should be avoided. Side effects are ofen dealt with by decreasing the dose or temporarily stopping MTX and then restarting it.
 
Gold has the potential of disease suppression.,but it is more toxic The refular dose is (50 mg./weekly). To mke sure the patient isn't sensitive to gold,two small test doses of aurothiomalate are given,one week apart. The practise in the past was to do this,once a week,until 1,000 mg. had been given,and some doctors may still do this. If the patient is no better,then they try another drug
 
The major disadavantage include the need to visit the doctor each week,the longer time for efficacy (12 to 20 weeks), Blood tests and urine tests are usually done prior to injection. Twenty weeks is a long time to wait to see if the drug works or not. If it does not work,it is valuable "wasted time" w.r.t. to the ongoing disease process.
 
Azathioprine is taken daily. The initial dose is one tablet (50 mg) and later the dose is adjusted according to the patient's weight. Later,if the patient has done well,the dose can be reduced without losing the effect. Once a regular dose has been settled on complete blood counts (CBC) are needed less frequently than with mtx and gold,but it should still be checked at least every 3 months.
 
Sulfazaline is used more in Europe. The British rank it somewhere near intramuscular gold. Its safety profile is excellent. It takes action in 2 to 3 months
 
There are some conflicting reports as to whether ssz is useful in some of the seronegative arthritis cases, PA and AS. SSZ should be started with a low dose and gradually built up. Start with one tablet (500 mg) a day for a week,then increase the daily dose by one tablet each week until, by the fourth week the patient is taking two tablets twice a day, there are other variations to this schedule.
 
Hydroxychloroquine HCQ) is considered to be much weaker than almost all the other DMARDs (plaquenil). It's safety profile is excellent It takes effect in 3 to 6 months ,but its long-term benifit is not so good as the others. In the case of severe RA,six months is a long time to wait,and find the drug ineffective.
 
It's very important to get a annual eye check up. The maximum daily dose is 400 mg-calculated w.r.t. bodyweight--200 mg/twice/daily.
 
Auranofin-oral gold has been proven to be a disappointment .There is little flexibility in the dose of auranofin- one 3 mg. tablet twice a day. A complete CBC and urinalysis /monthly. Long time for efficacy results-six months.
 
D-penicillamine and cyclosporin is not commonly used today . With the many alternative,including the newer biologics the two are on the "back-burner" but when every thing else fails,they are available-they have higher toxicity levels,and hard to control,at times.