Treatment of rheumatoid arthritis

A report presented to the department of medicine as a part of

The evaluation in internal medicine for the fifth stage

Presented by

‫سفيان معاوي سليمان‬

University of mosul

College of medicine

Department of medicine

Supervised by

Dr. Ali Abdul-Rahman Younis

Rheumatologist (FIBMS)

2019-2020
Contents
• Introduction
• General consideration
• Medical treatment
• Surgical treatment
• Summary
• References
Introduction

The treatment of rheumatoid arthritis (RA) is directed toward the control of synovitis
and the prevention of joint injury. The choice of therapies depends upon several
factors, including the severity of disease activity when therapy is initiated and the
response of the patient to prior therapeutic interventions.

How is rheumatoid arthritis treated?

The goals of rheumatoid arthritis treatment are to:

• Control a patient's signs and symptoms.

• Prevent joint damage.
• Maintain the patient’s quality of life and ability to function.

Joint damage generally occurs within the first two years of diagnosis, so it is important to
diagnose and treat rheumatoid arthritis in the “window of opportunity” to prevent long-
term consequences.

Treatments for rheumatoid arthritis include medications, rest, exercise, physical

therapy/occupational therapy, and surgery to correct damage to the joint.

The type of treatment will depend on several factors, including the person's age, overall
health, medical history, and the severity of the arthritis.

General considerations
Intensive target-driven treatment of RA, aiming for disease remission, is
recommended. All patients with RA should have access to regular meetings with
a rheumatologist. Patient involvement and shared decision-making is
essential in treatment planning
Non-pharmacologic therapies
Non-pharmacologic therapy is the first step in treatment for all people who have
rheumatoid arthritis. Non-pharmacologic therapies include the following:

Rest
When joints are inflamed, the risk of injury to the joint and to nearby soft tissue structures
(such as tendons and ligaments) is high. This is why inflamed joints should be rested.
However, physical fitness should be maintained as much as possible. Maintaining a good
range of motion in your joints and good fitness overall are important in coping with the
overall features of the disease.
Exercise
Pain and stiffness often prompt people with rheumatoid arthritis to become inactive.
However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle
strength. These, in turn, decrease joint stability and increase fatigue. Regular exercise,
especially in a controlled fashion with the help of physical therapists and occupational
therapists, can help prevent and reverse these effects

Specific types of therapy are used to address specific problems of rheumatoid arthritis

• The application of heat or cold can relieve pain or stiffness.

• Ultrasound can help reduce inflammation of the sheaths surrounding tendons
(tenosynovitis).
• Exercises can improve and maintain range of motion of the joints.
• Rest and splinting can help reduce joint pain and improve joint function.
• Finger-splinting and other assistive devices can prevent deformities and improve
hand function.
• Relaxation techniques can relieve secondary muscle spasm.

Occupational therapists also focus on helping people with rheumatoid arthritis continue
to actively participate in work and recreational activity, with special attention to
maintaining good function of the hands and arms.

Nutrition and dietary therapy

Weight loss may be recommended for overweight and obese people to reduce stress on
inflamed joints.

People with rheumatoid arthritis have a higher risk of developing coronary artery disease.
High blood cholesterol (a risk factor for coronary artery disease) can respond to changes
in diet. A nutritionist can recommend specific foods to eat or avoid in order to reach a
desirable cholesterol level.

Changes in diet have been investigated as treatments for rheumatoid arthritis, but no diet
has been proven to cure it. No herbal or nutritional supplements, such as cartilage or
collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not
usually recommended
Medical treatment
There are many medications to decrease joint pain, swelling, and inflammation, and
prevent or slow down the disease. The type of drugs that your doctor recommends will
depend on how severe your arthritis is and how well you respond to the medications

1- NSAIDs: for relieve of pain & inflammation (symptom-modifying).

o Aspirin 500 mg/ 4h

o Diclofenac 50mg t.d.s
o Paracetamol 500mg t.d.s
o Indomethacin 50 mg t.d.s
o Ketoprufen 100mg t.d.s
Mechanism :  PG through inhibition of cyclooxygenase enzyme.
S/E : Nephrotoxicity, hepatotoxicity, peptic ulcer.

2-Corticosteroids (oral and injectable forms)

Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow
joint damage. Side effects may include thinning of bones, weight gain and diabetes.
Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of
gradually tapering off the medication.

Intra articular injection of cortisone

Indication:
• Inflammation of tendon (e.g. tendon achillis).
• Used for joints that remain painful despite of general measures.
S/E: - Infection  septic arthritis

- Rebound pain.

3-Disease-modifying antirheumatic drugs (DMARDs)

- ↓↓ activity of the disease (↓ ESR, CRP) & ↓↓ progression.
- These drugs are slow acting drugs (their effect take 4-8 weeks to appear).
і- Gold salts : ( Na aurothiomalate )
Dose : 50 mg/week IM for about 20 weeks ( Total dose :1000mg)

SE: - Depression of bone marrow., Hypersensitivity , Proteinuria.

Precaution : -Stop if proteinuria  2g /24h , Stop if WBCs < 3000 or platelets <
100000
iі- Penicillamine: ↓↓ RF
 Dose : 250 mg/d
 Response : within 4-6 months.
 SE : As Gold + SLE.
iii- Chloroquine :
 Dose : 250 mg/d
 Response: Within 4-6 months.
 SE: Corneal opacity, GIT irritation, Skin rash.
 Precaution: Request fundus examination before use & every 6 months

4-Biological Treatment
These drugs are more effective than standard DMARDs (with a faster onset of
action, greater clinical efficacy and sustained benefit) but because of their cost
many countries have set restrictive guidelines for their use
Current recommendations are that biological therapy should be initiated only in
active RA (DAS28 > 5.1) when an adequate trial of at least two other DMARDs
(including methotrexate) has failed.
Tumor necrosis factor  (TNF  ) blockers
o These agents are used in severe active rheumatoid arthritis when standard
disease - modifying therapy has failed. (usually given in combination with
methotrexate)
o These drugs block the action of cytokines (chemical mediators).
O The onset of action is rapid compared with traditional disease - modifying
drugs (2 weeks)
o e.g.: Infliximab, Adalimumab.
Interleukin - 1 blocker (anakinra)
o It blocks the biologic activity of IL-1 including inflammation & cartilage
degradation associated with rheumatoid arthritis
Monoclonal antibody that binds CD20 antigen on B-cells surface (Rituximab)

Surgical treatment
If medications fail to prevent or slow joint damage, you and your doctor may
consider surgery to repair damaged joints. Surgery may help restore your ability to
use your joint. It can also reduce pain and improve function
Rheumatoid arthritis surgery may involve one or more of the following procedures:
Synovectomy. Surgery to remove the inflamed lining of the joint (synovium) can
be performed on knees, elbows, wrists, fingers and hips.
Tendon repair. Inflammation and joint damage may cause tendons around your
joint to loosen or rupture. Your surgeon may be able to repair the tendons around
your joint.
Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign
a joint and for pain relief when a joint replacement isn't an option.

Total joint replacement. During joint replacement surgery, your surgeon removes
the damaged parts of your joint and inserts a prosthesis made of metal and plastic.

Summary
1-The treatment of rheumatoid arthritis (RA) is directed toward the control of
synovitis and the prevention of joint injury
2-Non-pharmacologic therapy is the first step in treatment for all people who have
rheumatoid arthritis
 3-There are many medications to decrease joint pain, swelling, and inflammation,
and prevent or slow down the disease (NSAIDs, corticosteroid ,DMARDs)

4- Biological Treatment: These drugs are more effective than standard DMARDs
(with a faster onset of action, greater clinical efficacy and sustained benefit) but
because of their cost many countries have set restrictive guidelines for their use
5- If medications fail to prevent or slow joint damage, you and your doctor may
consider surgery to repair damaged joints

References
1-NICE. Rheumatoid Arthritis in Adults: Management (Last updated: December
2015). London: NICE. http://www.nice.org.uk/guidance/cg79

2- Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the

management of RA wit synthetic and biological disease-modifying antirheumatic
drugs: 2016 update. Ann Rheum Dis 2017;76:960–77.
http://ard.bmj.com/content/early/2017/03/06/annrheumdis-2016-210715

3- Ding T, Ledingham J, Luqmani R, et al. BSR and BHPR RA guidelines on safety

of anti-TNF therapies. Rheumatology 2010;49:2217–9.

4- Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology
Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken)
2016; 68:1.

1. 5- Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to

target: recommendations of an international task force. Ann Rheum Dis 2010;
69:631.